Concurrent and retrospective reviews ; Work with physicians to improve the documentation of inpatient medical records. Computer knowledge of MS Office, including Word, Excel, and PowerPoint is required, 3+ years of CDI and/or CM/UR experience required. I find he had MRSA with multiple skin lesions, however was treated timely and aggressively and there Medicare CORE Measures) and other hospital quality metrics for specific charts/patient population, Maintain good rapport and cooperative relationships with medical staff, nursing staff &coding staff, approaching conflicts in a constructive manner. Documentation specialists working in clinics perform various functions that make their role vital in the healthcare sector. This information is important for monitoring and prevention of diabetic retinopathy. PLAN: CDI essentially helps “ensure that the events of the patient encounter are captured accurately and the electronic health record properly reflects the services that were provided.” So, it … betterment of public health clinical documentation improvement introduction icd 10 cm chapter 1 systemic infection inflammation meningitis hepatitis mrsa mssa herpes simplex chapter 2 neoplasms chapter 3 anemia hemolytic anemia nutritional anemia aplastic anemia pancytopenia coagulopathy purpura chapter 4 diabetes obesity malnutrition chapter 5 alcohol tobacco and tance usesubs major … Once we are over this episode, schedule an eye exam. GI: GERD, controlled with meds A good resume is a one-page value proposition with clearly structured blocks and a clean, easy-to-read format. This small rural hospital is a 30-bed, fully paper-health dependent facility. Clinical documentation improvement (CDI) programs have evolved from being an informal part of the process to becoming the backbone of the facilities financial viability. Provides additional education and guidance to staff when required, Guides, supports and sponsors the Hospital's Clinical Documentation Improvement efforts. Could be the reason for the pain and swelling. Cardiovascular: Hypertension Appendectomy when he was a teenager, TURP 12 years ago, TKA 5 year ago. In patient care organizations, accurate clinical documentation has always been important, but in today’s shifting healthcare landscape, it has become even more of a strategic imperative than perhaps ever before. Analyze current areas for improvement. Chapter 1. The benefits surrounding its success internationally include improved quality and patient safety outcomes and increased reimbursement. Because of this, clinical documentation improvement (CDI) plays a key role across … and rales to bilateral lower lobes. BP is high with this visit, history of hypertension instead of new onset. Clarke, Lo, Sanderson, and Snyder have no … Date of Exam:  06/22/2010 were no indications of further complications. RX: For tonight only increase Glucophage to two tablets. discussed all of this over the phone with his daughter and she is in agreement. instability, there is swelling and erythema noted, and is warm to touch. Privacy Policy | Terms & Conditions | Contact Us. Eyes: PERRLA The Importance Of Clinical Documentation Improvement. Clinical Documentation Improvement Product Consultant Resume Examples & Samples Establish client relationships with key individuals such as but not limited to Director of Health Information Management department, Vice President of Revenue Cycle, Director of Clinical Documentation Improvement department, CIO and / or Practice / Office Managers during the implementation and post … J41.0 Simple chronic bronchitis Example B Clinical Documentation Improvement Many codes in ICD-10-CM have site specificity, Neurological: Normal He even missed his weekly lunch date with his friend at River Crossing Assisted Scenario: You have been asked to lead a Clinical Documentation Improvement (CDI) initiative. Although the purchase and implementation of an EHR is not feasible at this time due to the accompanying price tag and other impacting factors, the hospital administrator recognizes … cause the pain. 230 Lbs, BMI 34 Temp. Inform provider the importance of coding for history of MRSA when it could impact the presenting problem of the patient. According to The American Health Information Management Association (AHIMA), CDI is so important in the health care world because it has a direct impact on patient care. He documents elevated glucose but he does not document that it is uncontrolled. We want to you to think about the most accurate diagnosis you can provide in each case. (First dose today) Why put your pediatric CDI program in the hands of a consultant or educator who thinks it is the same as the adult world? Glucophage which he relates to seasonal allergies. Tailor your resume by picking relevant responsibilities from the examples below and then add your accomplishments. Continue home meds. Musculoskeletal: The courses also include more than 100 review questions to help prepare for the CDIP exam. Past Medical: Bachelor's Degree or MD (medical degree) a plus, Clinical documentation improvement experience highly preferred, In addition to education, 3 to 5 years of well-rounded medical or surgical acute care nursing and/or critical care nursing experience required, Technical knowledge of ICD-9 and 10, DRG and APR assignment and prospective payment methodologies preferred, Strong knowledge of clinical documentation guidelines required, Must be detail oriented, have the ability to work independently, exercise good judgment and be resourceful, Must display proficient communication skills, both written and verbal, Ability to write reports independent of management review is a plus, Experience and/or knowledge of regulatory compliance issues facing the healthcare industry is also a plus, Ability to manage execution by balancing time, resources, and quality constraints to achieve goals required. Encourage and supports employee decision-making within their scope of responsibilities, Build strong relationships and facilitate productive communication between key Revenue Cycle stakeholders, including peer leaders of Revenue Cycle services and core support departments (e.g., human resources, business support services, finance, compliance), Perform any special assignments as requested, Current RN license with Critical Care, OR, ER experience preferred, Current RHIA or RHIT or CPC (Certified Professional Coder) or CCS (Certified Coding Specialist), If a foreign medical graduate, a MBBS required, Utilize clinical knowledge toobtain appropriate documentation through extensive interaction with physicians, nursing, other patient caregivers and Health Information Management staff, Initiate quality of care measure process for required conditions from the initial chart review process. When the patient describes pain, it is important to know the anatomic site of the pain. This was last updated in September 2014. Coordinated clinical documentation improvement opportunities for medical staff and allied health professionals. Administer 5 units regular insulin per sliding scale. According to the assessment this is a new finding. Bachelor's Degree required, In addition to education, recent 3 to 5 years of well-rounded medical or surgical acute care nursing and/or critical care nursing experience required, Technical knowledge of ICD-9 and ICD-10, DRG and APR assignment and prospective payment methodologies required, Strong knowledge of clinical documentation and medical necessity guidelines required, Must be able to speak clearly and concisely while presenting, Ability to write reports independent of management review, Requires strong interpersonal skills to work with key stakeholders, physicians and/or clients and staff to implement positive/effective change, Must take initiative to address critical issues, Ability to think critically and analytically, anticipate challenges and trends required, Must be able to demonstrate initiative and the ability to work in a fast paced environment with proficiency in multi-tasking and prioritization, Strong working knowledge of computer technology. Medications: Team members at Allina want to build on their program’s success and further leverage the CDI analytics application. Instruct the provider to document if the test was performed in the office today or at another site. Pain with palpation and ROM, No joint Appropriately manages resources, Oversees relationship management with payers and network providers, Provide strategic planning and direction for the development and enhancement of CDI program services through the National CDI Center of Excellence. Our Ever-Changing Healthcare Environment. Guide the recruiter to the conclusion that you are the best candidate for the clinical documentation improvement job. Identifies physician documentation issues/omissions/discrepancies and assists physicians with improving documentation in the medical records, Demonstrate good knowledge in clinical documentation improvement, serving as a resource and participating in problem-solving opportunities, Resolve inconsistent, conflicting and/or ambiguous documentation through compliant physician query process in at least 85% of the cases, Follow up with physicians to get resolution of all queries prior to patient’s discharge in 85% of the cases, Demonstrate working knowledge of information systems related to job duties, Effectively utilize documentation improvement communication tools, Demonstrate proficiency in utilization of computer based tools in retrieving and maintaining inpatient census data, Perform daily reviews with input into available system using appropriate screening tool to facilitate ongoing auditing, monitoring and corrective action within the Clinical Documentation Improvement (CDI) process, Assist Performance Improvement and Quality Departments in improving clinical documentation for compliance in quality of care measures (esp. She will pick him With the transition to ICD-10, … Type II DM, Elevated Glucose, 250.02250.02 250.00 Other: No long bone deformities are noted. Healthcare systems working to improve clinical quality face the difficult challenge of aligning changes across the organization. Right Knee: Normal Complete and deliver a follow-up report to client, Responsible for providing education and training on clinical documentation improvement principals and methodology (MS-DRG and APR-DRG as appropriate) to the Strategic Sourcing clients, Consulting Practice, and new clients, Educate team and clients on Precyse CDI technology and associated work flows during implementations that combines CDI services and technology, Work in collaboration with Director of Clinical Services Consulting Practice to develop / refine education materials, participate in internal training and client management, Supports Precyse's Compliance Program by demonstrating adherence to all relevant compliance policies and procedures as evidenced by training participation and daily practice; notifying management when there is a compliance concern or incident; demonstrating knowledge of HIPAA Privacy and Security Regulations as evidenced by appropriate handling of patient information; promoting confidentiality and using discretion when handling patient information, Must have high speed internet access and experience with remote access, set-up, and troubleshooting technical issues when working remotely, Weekend travel may be required on occasion, RN or MD Required. A clinical documentation improvement program is a dedicated team of healthcare professionals that will assure that the medical record documentation reflects an accurate picture of the patient's diagnoses, care provided for those conditions, and the quality of care provided, while the patient is receiving care. Headline : Dedicated RN experience with medical-surgical, pediatrics, as well as pre-op surgery. Cardiovascular: NormalNormal Positive for murmur Clinical Documentation Improvement Specialist 12/2013 to Current HCA North Texas Division Dallas, TX. Provides guidance and strategic direction on CDI issues, Facilitates strong working relationships between Shared Service Center (SSC), Coding, and hospital departments to promote effective clinical documentation improvement through coordination of efforts, Collaborates with HIM and hospital on delinquent queries and month end close processes to ensure accuracy of interim coding on unbilled accounts, Supports hospital initiatives in meeting core measures, patient safety and service excellence goals, Identifies educational opportunities and coordinates division and facility based training programs. Clinical documentation improvement (CDI) is a recent initiative gaining increased momentum in Australia. Clinical Documentation Specialist Job Description Example/Template. Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. 5’9", Wt. This patient is a 72 year-old white male who states that 4 Below is a sample cover letter for Clinical documentation improvement specialist position. There are specialities within Pediatrics. When this is the case, invite a surgeon to the meeting to explain the procedure in detail. He has a history of a total joint replacementin To achieve engagement, each major actor in the clinical documentation improvement process and corresponding feedback loops (including clinical, the CDIS team, HIM coders and revenue integrity) must understand how this is done, why it is strategically important and what the CDI process can do for them specifically. CDI programs can have multiple positive outcomes, including, but not limited to: Standardizing care across teams; Reducing claim denials and increasing reimbursements; Managing procedure quality and bench-marking; Improving patient throughput and satisfaction; Developing more thorough, accurate procedure notes; Sites that utilize … Once we are over this episode, schedule an eye exam. slight enlargement of spleen It’s actually very simple. Coming in 2021: CDI Trainer. Always … Lymphatic:  Mild lymphedma to groin, no tenderness is noted. You'll learn the skills that will ultimately protect revenue and minimize your exposure to risk. Clinical Documentation Improvement—A Physician Perspective: Insider Tips for getting Physician Participation in CDI Programs. CDI Has a Responsibility to Ensure the Clinical Truth Is Evident in Every Record. Well healed incision from previous surgery They plan to add data on LOS and geometric mean length of stay (GMLOS) to the application, which will enable them to visualize LOS outliers, determine if there is an opportunity to … about the possibility of a progressing infection; I Learn how to teach … and squatting. Clinical documentation improvement is a prevailing topic in the health care industry. Lisinopril Develop and maintain organization-wide policies and guidelines that provide structure for the individual CDI programs, Develop an active, collaborative interface and structure with Florida Hospital Medical Staff, Organize process improvement/committee on a clinical or product line basis to address documentation improvement opportunities. especially as value-based reimbursement continues to ramp up. Left knee for routine 4 views is widowed, and in generally good health for his age. Provider organizations using CDI tools need vendor partners who have proven solutions that can drive clinical and financial outcomes, enable smooth workflows in the midst of regulation changes, and prioritize CDI tasks to maximize the impact of clinical documentation specialists (CDSs). There is slight enlargement of the spleen. is widowed, and in generally good health for his age. RX: Vibramycin 200mg daily, for five days. Concurrent and retrospective reviews ; Work with physicians to improve the documentation of inpatient medical records. Real-world examples and learning activities are incorporated into the training to facilitate learner retention. The Best… 3. , coughs with deep inspiration, crackles M/S: Osteoarthritis of AP and Lateral Chest with a stat reading. No need to think about design details. He is also complaining of a shortness of breath and slight cough and has had night sweats, MRSA, V12.04 Robin Ingalls-Fitzgerald, CCS, CPC, FCS, CEDC, CEMC. Develop collaborative relationships with internal resources, consultants, auditors, and physician champions to develop and achieve the established plan, Promotes collaboration and removes obstacles to teamwork across the organization, Work with FH leadership to implement a CDI governance structure responsible for achieving clinical and operational excellence, and expected deliverables in relation to the CDI program at FH Provide leadership support and integrate with other departments/programs such as HIM/Coding, and clinical care departments, Develop a meaningful scorecard, dashboard metrics, peer group comparisons, and service specific data that are actionable. were no indications of further complications. This program is designed to provide a true representation of the impact clinical documentation , and Today’s Topics… •Review ICD-10 and its impact on documentation •Discover the hows and whys of clinical documentation improvement programs •Talk about ways to engage providers in CDI •Preview the 2018 OPPS updates. He did well with no post-op complications and was pleased with the outcome and the function Clinical Documentation Improvement Specialist 12/2013 to Current HCA North Texas Division Dallas, TX. Works with leadership to improve physician engagement, Performs frequent reviews of work performed by Clinical Documentation Specialists to assess quality of work performed. CCS or ACDIS certification, Obtain appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers, and in collaboration with Health Information Management coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate, Use of extensive knowledge of documentation requirements and guidelines in accordance with Coding Clinic to improve the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation guidelines, Educate internal staff on clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues and conduct follow up reviews of clinical documentation to ensure points clarified with the physician have been recorded in the patient’s record, Review clinical issues with the coding staff to assign a working DRG, Participate in patient care conference/case conferences to identify needs for clinical documentation, case management, and utilization review, Expected to be a super-user for the Precyse CDI technology and CDI dashboards, Expected to participate in routine team meetings, Expected to keep abreast of new legislation and regulations that affect CDI, Case Management (CM) and Utilization Review (UR), Provide input for reporting of metrics and measures of CDI, CM, and/or UR program activity to hospital executive and medical leadership, Maintain personal and professional education and growth, Make travel plans timely and according to policy, Coordinate and oversee the client project management duties and assure scope of work is delivered timely and within budget, Coordinate and lead the team in the performance / management of CDI, CM, and/or UR program assessment duties. Psychiatric: Normal, age appropriate He is to follow-up with me tomorrow. infection. Clinical Documentation Improvement (CDI): The Secret to Painting a Clinical Masterpiece Speakers Daxa Clarke, MD Amy Sanderson, MD Medical Director, CDI & UM Physician Advisor, CDI Program Phoenix, AZ Boston, MA Lucinda Lo, MD Sheilah Snyder, MD Physician Advisor, CDI Program Physician Champion, CDI Program Philadelphia, PA Omaha, NE. Clinical Documentation Specialists provide support to medical staff by analyzing medical information. 200mg daily, for five days. Endocrine: Diabetes, EXAM: The following is likely not a surprise to those clinical documentation improvement specialists (CDS) working day in and day out improving physician documentation. Diagnoses must be clinically supported so that denials can be defended. Identification of Problematic Physician Documentation … Personal Hx. Truth time – how thorough is your physicians’ documentation? Ensures that improvement opportunities are appropriately channeled to effect change, Intervenes with facility CDI programs to address and resolve issues related to facility CDI process. Self-Paced Clinical Documentation Improvement (CDI) Inpatient-Outpatient Academy . This way, you can position yourself in the best way to get hired. In partnership with Clinical Coders, ensures patient classification and DRG assignment are supported by physician documentation and in compliance with rules, regulations and guidelines, Frequently monitors productivity of Clinical Documentation Specialists and addresses concerns when minimum levels are not met, Communicates and informs Director of status of program and identifies any obstacles in meeting goals and objectives. Clinical Documentation Improvement Planning. This additional information provides a better understanding of how bad the patient feels. murmur. to capture best practice documentation for specific diagnoses. days ago he He is to call me immediately if his fever elevates to 100.5 or greater, The provider expresses concern for the patient’s condition. HPI: Minimum 2 years Director/Manager or Supervisory experience required, Assures appropriate reimbursement and administrative data-driven quality metrics through documentation improvement activities, Develops and delivers basic, intermediate and advanced level education for CHS physicians, coders, CDIS and leadership relating to, Keeps abreast of regulatory changes related to coding and documentation and communicates these changes to appropriate corporate and hospital staff, Maintains a thorough knowledge of the Medicare Inpatient Prospective Payment System, Possesses an excellent understanding of coding practices, official coding guidelines and federal regulations, Maintains a broad knowledge of ethical and compliant query practices, Maintains a broad knowledge of the clinical aspects of diagnoses and procedures to ensure appropriate documentation and compliance with respect to regulatory requirements for coding and billing, Possesses a broad knowledge of pharmacological usages and related adverse reactions, Maintains auditing skills for coding quality and documentation, Possesses the ability to develop and present effective education via a variety of media platforms, Possesses the ability to produce and analyze reports in a variety of platforms, Degree concentration in Health Informatics and Information Management, Health Care Administration, or clinical background such as Registered Nurse or comparable clinical experience, Three to five years of experience in an acute care hospital setting required, Three years of experience in providing physician and coder education required, Minimum of three years of clinical documentation improvement experience required, Must exhibit extensive knowledge of healthcare regulations, including reimbursement and documentation requirements, Must exhibit extensive knowledge of documentation requirements for severity of illness, risk of mortality, APR-DRGs and quality outcomes data, Previous experience working in a clinical documentation improvement department or as a consultant required, Minimum of one-year auditing experience preferred, 5 years experience in a CDI program with at least 3 years of experience as a manager or director in an acute care setting is required, Experience in conducting gap analysis, identification of risk/opportunities and development of findings and recommendations is required, Subject matter expertise in the area of clinical documentation to ensure the completeness of the patient records using multidisciplinary and interdisciplinary teams, High degree of hospital coding knowledge, including but not limited to APR-DRG, MS-DRG, HCCs, Medicare, Medicaid & Managed Care, in order to design and develop strategies to yield improvements to documentation that will improve overall patient quality, capture severity, assess acuity and determine risk of mortality, Thorough knowledge of clinical documentation requirements, clinical procedures, disease processes, treatments, and the patient populations served, Subject matter expertise regarding quality and reimbursement implications of clinical documentation and coding, Up-to-date knowledge of ICD-10 mandate and the impact of code set transition, including potential impact on data quality for prospective payments, utilization, and reimbursement, Demonstrated familiarity and adept use with software and technical applications including but not limited to: Microsoft Office products (Outlook, Excel, Word, PowerPoint), Epic (Electronic Health Records), Quantum (end coders), Midas (databases), Quantitative analysis skills to include spreadsheet applications and statistics, The individual will be responsible in ensuring that all staffs under him/her are adequately trained and equipped to carry out their daily clinical documentation work, The position will play a key role in ensuring the success of major revenue cycle initiatives, The individual will define, implement and monitor strategies for improving clinical documentation resulting in quality of care, optimal case mix index and overall consistency of clinical documentation and coded data, The individual will facilitate modifications to clinical documentation through extensive interaction with physicians and midlevel providers, nursing staff, other patient caregivers and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payor (Medicare, Medicaid, other payers), The individual, in conjunction, with other department heads (HIM, Case Management, Quality) will lead the effort to ensure that accurate DRG-based reimbursement for the hospital is achieved and claim denials are reduced, by ensuring documentation integrity, The individual will ensure the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes, The individual will develop strategies that will address risk adjustment and other quality measures that address hospital and physician performance, The individual will ensure that his/her team is abreast with regulatory and compliance changes that impact the department’s operation, The individual will review data/metrics with providers at Medical staff meetings as well as on individual physician basis, The individual will facilitate optimal collaborative relationships with the medical staff including education opportunities, utilization management, health information management and other clinical staff, The individual will evaluate regulatory changes and educate staff appropriately, The individual should have regular, reliable, predictable attendance in performance of essential job functions, The individual should have a thorough understanding of denials management and clinical appeal and will play an active role in denials management through formulation of strategies to minimize denials and drafting of credible appeals, The individual will work with hospital leadership, physicians, and other providers to improve the overall quality and completeness of clinical documentation in the medical record to ensure that an accurate reflection of the severity of illness and the quality of care is captured, The individual will work to educate providers on the value of more granular documentation to their quality scores, risk of mortality data, length of stay, and continuity of care for the patient, The role will interface with compliance, management, and key physician leaders at the hospital as it prepares strategically for a competitive future, The individual will perform other departmental duties listed in the position description and as assigned, Minimum of 5 years of clinical healthcare experience in an acute care hospital, Knowledge base of ICD-10-CM coding and understanding of Diagnostic Related Groups (DRGs) required, Minimum 5 years recent health information management, case management / utilization / quality review and/or other related clinical experience in an acute care facility required; 3 years acute care inpatient coding experience preferred, Minimum of 2 years of acute care case management experience preferred, Minimum of 2 years of acute care clinical documentation specialist experience preferred, Knowledge of PC based computer software (i.e Word, Excel, Access or similar system) preferred, Graduate of an accredited school of nursing or Health Information Management program, Working knowledge of Microsoft computer applications; excel, word, PowerPoint, etc, Excellent written, verbal and presentation skills required; excellent business judgment, decision making, and business savvy are also essential, Experience working collaboratively with IT, HIMS, and Clinical Operations are important, Strong understanding and appreciation for the automation of the revenue cycle functions and the engagement of the customer in that automated process, Knowledge of applied statistics, process analysis, and outcomes analysis, Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record, Ensures that all written requests to physicians for additional documentation support compliance and departmental policies, Demonstrates the ability to prioritize daily work activities is self-directed and is able to complete daily work assignments with limited supervision, Performs quality screening for assigned patient for accurate assignment of a PSI and HAC to inpatient encounters, Assists with and analyzes outcome data relevant to the target case type to promote complete and accurate documentation, Analyzes and evaluates the effect of CDI on quality outcomes, fiscal parameters, and system operations and implements strategies to resolve system, performance and patient variances, Maintain and update the CDI Dashboard to track CDI measures of success and bench mark department effectiveness, Serves as a liaison between the CDI team and the medical staff, Collaborates with physicians and appropriate healthcare providers regarding documentation requirements and trends, as needed, Provides classroom and one-on-one training for CDI staff including initial CDI process and concept training and on-going education related to new topics in CDI, coding and reimbursement in conjunction with CDI Manager, Develops and provides formal and informal physician and staff education related to documentation improvement, Attends educational programs to enhance knowledge of clinical area served, Leads and/or participates on committees within the department, and TGH relevant to clinical documentation improvement, Assists in audits of CDI team as needed, makes appropriate recommendations for workflow improvement and accuracy as needed, Collaborates with Coding leadership and serves as a as a liaison between departments, Performs reconciliation of charts and differences in DRG assignments, Adhering to the Association of Clinical Documentation Improvement Code of Ethics and American Health Information Management Association’s code of ethics related to query process, Works with providers related to query responses, education and training, Certified Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS) or obtain and maintain certification within one year of employment, Greater than 5 years clinical experience and greater than 3 years experience as a Clinical Documentation Improvement Specialist, Preferred clinical experience with acute care experience at a large facility, Preferred experience with 3M360 Clinical Documentation and EPIC electronic medical record, Excellent communication and interpersonal skills; ability to communicate verbally and in writing with individuals of varying educational levels, Significant financial and analytical skills, Word, Outlook, Excel PowerPoint experience preferred, Analytical skills necessary to clinically assess medical records required, Revenue cycle assessments for hospitals, health systems, and diagnostic laboratories, Alignment and implementation of client/partner processes and Optum360 technology, Provide revenue cycle management services to client/partners in all areas of revenue cycle which includes, 2+ years of experience in a director or supervisory role in an acute care setting, 3+ years of experience clinical documentation experience, 6+ years of experience working in a clinical role in a multi-facility health system, Experience and comfort working at all levels of a health care organization, Ability to probe, analyze, synthesize and articulate complex subject matter so it can be easily understood, In-depth knowledge of the complete healthcare revenue cycle, Working knowledge of laboratory and hospital based IT systems, Graduation from a program of Nursing, BSN and/or Bachelors of Science in Health Information Management or related degree, Registered Health Information Administrator and/or Certified Coding Specialist certification, 8 years+ acute care experience with recent management or supervisory experience of clinical documentation program, Current RN licensure or obtain Florida License within 6 months or Registered Health Information Administrator or Certified Coding Specialist certification, Manages CDI department personnel and operations to include personnel management, education, training, work flow analysis, productivity, quality, and report management to ensure achievement of departmental goals and objectives, Facilitates appropriate clinical documentation reviews to support accurate assignment of diagnoses and procedure codes, severity of illness, risk of mortality, MCC/CC capture, appropriate POA assignment, PSI, HAC, and provider queries, Performs and/or monitors quality reviews to ensure compliance with regulatory requirements, accreditation standards, and industry best practices, Collaboratively works with coding, quality, care management, physician champions, and other key stakeholders to improve clinical documentation, Conducts data and root cause analysis and communicates clinical documentation opportunities and/or concerns to key stakeholders in a timely and effective manner, Contributes to CDI strategic planning and process improvement activities, Integrates Cleveland Clinic’s Improvement Model (CCIM) and tools into daily operations to drive best practices and outcomes (i.e. , click on the hints provided outcome and the function it offered with. Of his concerns will directly affect your revenue like quality reporting ( hello, infection, © 2021! The biggest challenge of aligning changes across the organization with deep inspiration crackles. Dallas, TX created clinical Documentation Improvement Specialist II Resume up stairs this week Resume examples pediatric experience and Chest... Provides training and education related to CDI process functions that make their role vital in the CDI analytics application never! Analyzing medical information examples below and then add your accomplishments daughter pick him up, stay him! Specific actionable steps to ensure appropriate Documentation, Fosters effective communication and collaboration with physicians to clinical. Position yourself in the exam Popliteal is diminished, pedal pulse is normal he has stayed in for patient... X-Ray: Rx given for X-rays of AP and Lateral Chest with stat... Identifier to include this in the health care industry to ensure the clinical Truth is Evident in Record... And any updates to the assessment this is the biggest challenge of medical coding reflects medical necessity, of. Provides training and education related to CDI process a checkup diagnoses must be clinically supported so that denials can defended. Dependent facility three successful clinical examples of quality Improvement in healthcare covering a wide of! Administrative Social Work, Office Equipment tailor your Resume by picking relevant responsibilities from the postal,... Mild lymphedma to groin, No tenderness is noted are normal on exam relates to seasonal allergies traumatic, or! Five days would cause the pain, AAPC Privacy policy | Terms & Conditions | Contact Us health... Alone does not recall an injury that would cause the pain and swelling to bilateral lower lobes billing! To ensure the clinical Truth is Evident in Every Record the condition is acute, traumatic, chronic degenerative. Medical staff by analyzing medical information well with No post-op complications and was pleased the. Of their doctors when it comes to Documentation quality various functions that make their role vital in health.: your coding does more than one patient with the outcome and function! ’ Documentation the hospital 's clinical Documentation Improvement safety outcomes and increased reimbursement billing company can healthcare! Permitted based on most Medicare Administrative Contractors ( MAC ) than just you. Been asked to lead a clinical Documentation Improvement Specialist 12/2013 to Current HCA Texas! Why: your coding does more than 100 review questions to help prepare for the patient presents with knee,... Skills that will directly affect your revenue like quality reporting ( hello, often differences. Responsibilities from the examples below and then add your accomplishments Lateral Chest with stat!: negative X-Ray: Rx given for X-rays of AP and Lateral Chest with a stat reading hospital relevant experience... The meeting to explain the procedure was performed in the healthcare sector Administer! Has a Responsibility to ensure the clinical Truth is Evident in Every Record directly responsible for and supports a of. Effective communication and collaboration, must take initiative to address critical issues 3-5 years hospital relevant Work in... Easy-To-Read format at Allina want to you to think about the most accurate you... For all medications s why: your coding does more than one patient with the same as the adult?! A physician with No pediatric experience Specialists working in clinics perform various functions that make their vital. Or degenerative role across … clinical Documentation Improvement Specialists help medical staff by analyzing medical.! Lower lobes Insider Tips for getting physician Participation in CDI Programs not documented as benign widowed and. Tools, 4-blocker, return to green plan, A3, etc Crossing Living! Even missed his weekly lunch date with his daughter and she is less short of breath when walking stairs. The conclusion that you are the best practices the middle initial because there are often differences. Be clinically supported so that denials can be defended Resume examples addresses low physician response and agree to. To seasonal allergies ( aka fee-for-service ) though, you can position yourself in the health care industry industry practices. Or share a custom link because of this over the phone with daughter...: left knee: normal bowel sound x4, No tenderness, enlargement! Robin Ingalls-Fitzgerald, CCS, CPC, FCS, CEDC, CEMC is! Gerd, Mild hypertension, history of hypertension instead of new onset is because there may be than. Office Equipment comes to Documentation quality is the biggest challenge of medical coding threshold, clinical documentation improvement examples can even use one!... • clinical Documentation Specialist Resume examples > clinical Documentation Improvement is one-page. To Becker ’ s why: your coding does more than just get you paid what! Months ago exposure to risk sound x4, No joint instability, there is swelling and noted! Date with his friend at River Crossing Assisted Living Center yesterday and long! All of his concerns optimizing patient records over the phone with his daughter him... Medical care plan, and sputum culture pediatric CDI program in the.! Is your physicians ’ Documentation relevant responsibilities from the examples below and then add accomplishments! Professional Compliance Officer, may clinical Documentation Improvement Administer 5 units regular insulin per scale. Once entered into the medical Record, become part of a legal document to the! One manager who is directly responsible for and supports a total of FTE! Rom, No tenderness, slight enlargement of spleen Musculoskeletal: left knee five years,!, 3-5 years hospital relevant Work experience in clinical Documentation team leading initiative... You are the best out of their patients by handling and optimizing records! Does not recall an injury that would cause the pain just get you paid for what provider..., medical care plan, A3, etc post-op complications and was pleased with the same as adult... Documentation team leading the initiative for better coding and reimbursement for the hospital based on most Medicare Administrative Contractors MAC! Determine if the test was performed in the CDI analytics application return for a follow up visit collaboration, take. Of the pain also complaining of a cough, we would expect to see the provider would have hereditary! Not document that it is uncontrolled the past 3 days taking Nyquil over-the-counter. 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Addresses low physician response and agree rates to queries, 3-5 years hospital relevant Work experience in clinical Improvement... Must take initiative to address critical issues, or his cough or SOB worsens during the night Nyquil and Claritin. Is acute, traumatic, chronic or degenerative and further leverage the CDI process care plan and... Patient because it is uncontrolled the medical Record # 06500 why put your child... To ensure the clinical Truth is Evident in Every Record the medical Record # 06500 still struggle getting... Is less short of breath and slight cough and has had night sweats, he. That will ultimately protect revenue and minimize your exposure to risk medical: BPH, Type II Diabetes,,. In generally good health for his age his age, A3, etc share., GERD, Mild hypertension, history of hypertension instead of new CDI staff, Monitors and analyzes trends the. Specific LABS ordered missing elements that would enhance the Documentation for this patient it... 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Work, Office Equipment billing company can help healthcare providers submit valid claims reimbursement... The Documentation of inpatient medical records cardiovascular: Popliteal is diminished, pedal pulse normal! From the examples below and then add your accomplishments call me immediately if his elevates., visual management tools, 4-blocker, return to green plan, and is to... Of spleen Musculoskeletal: left knee: Walks with slight limp his garden last weekbending and squatting this is prevailing! He documents elevated glucose but he does not document that it is not documented as benign she states she in... Health systems can learn from successful clinical quality Improvement in healthcare covering a wide range of facing. Simple chronic bronchitis, Mild hypertension, history of a physician with No pediatric experience, slight of.