whiles ensuring that the chain of command is followed within the department, Utilize clinical knowledge to obtain appropriate documentation through extensive interaction with physicians, nursing, other patient caregivers and Health Information Management staff, Perform initial chart reviews and assign working DRG within 24 hours of admission, on the working days, Demonstrate good knowledge in clinical documentation improvement and participate in problem-solving opportunities, Maintain good rapport and cooperative relationships with medical staff, nursing staff &coding staff, approaching conflicts in a constructive manner, High degree of clinical knowledge and hospital coding knowledge (i.e., APR-DRG, MS-DRG, Medicare, Medicaid & Managed Care), Five years progressively responsible leadership experience, At least five years of experience as a CDI director or manager in a large acute care hospital setting, Master’s degree in Nursing, business or health related field (preferred), Current, valid State of Florida license as a registered professional nurse, Certified Clinical Documentation Specialist (CCDS) or Certified Coding Specialist (CCS) credential (preferred), Ensure standardization throughout the existing CDI programs according to industry leading practices. Instruct providers to include the anatomic site and number of views when ordering X-rays. After questioning further, Constitutional: Hgt. Coding and Clinical Documentation Improvement. Continue home meds. ENMT:  Normal other than nasal inflammation, dentures Instruct the provider to document if the test was performed in the office today or at another site. Pediatrics is not a specialty. She will pick him According to the assessment this is a new finding. 200mg daily, for five days. He documents elevated glucose but he does not document that it is uncontrolled. Without clinical insight, for example, it may be difficult to improve documentation identifying postoperative complications versus expected outcomes that are integral to a procedure. The benefits surrounding its success internationally include improved quality and patient safety outcomes and increased reimbursement. Below is a sample cover letter for Clinical documentation improvement specialist position. The type of diabetes must be documented. Clinical documentation quality is the biggest challenge of medical coding. After questioning further, Diagnoses must be clinically supported so that denials can be defended. Hypertension, 401.1401.1 401.9 DTRs are normal. about the possibility of a progressing infection; we discussed the possibility of a systemic In examining … Clinical documentation improvement (CDI) programs have evolved from being an informal part of the process to becoming the backbone of the facilities financial viability. Rapid influenza test performed in the office: negative You would never put your sick child in the hands of a physician with no pediatric experience. When the patient describes pain, it is important to know the anatomic site of the pain. Download Clinical Documentation Improvement Resume Sample as Image file, Clinical Documentation Specialist Resume Sample, Global Clinical Development Lead Resume Sample, Clinical Documentation Improvement Specialist Resume Sample, Director, Clinical Development Resume Sample, Responsible for recruiting and providing support, guidance and mentorship to Clinical, Oversees expense including resource utilization for supplies and staff, Establishes and maintains communication with Financial Planning and Revenue Cycle Business Analytics team, Rehires within 12 months are not eligible, Contribute to the design and development of a clinical documentation improvement program in coordination with hospital and division leadership, Collaborate with peers regarding department budget and operational plan development to maintain fiduciary responsibility and achieve greater financial performance, Up-to-date knowledge of ICD-10 mandate and the impact of code set transition (e.g., potential impact on data quality for prospective payments, utilization, and reimbursement), The individual will promote accurate concurrent documentation from all disciplines (physicians, case managers, nurses, dietitians, wound care specialists etc.) Must include the medication and dosage. Examples include: concurrent record review rate, concurrent query rate, query response rate, top query trends, CDS productivity EHR Optimization for Reporting Hospitals can choose from a myriad of software platforms geared toward clinical documentation improvement, case management and computer-assisted coding to Performs chart reviews to ensure appropriate documentation, Fosters effective communication and collaboration with physicians and/or provides training and education related to CDI process. He should document when the patient should return for a follow up visit. She says the albuterol is helping her breathing. He even missed his weekly lunch date with his friend at River Crossing Assisted Treat immediate hyperglycemic condition. Tips for Approaching Clinical Documentation Improvement As accurate clinical documentation becomes more important, it's vital to consider multiple approaches to clinical documentation improvement. Closing gaps in clinical documentation leads to improved revenue and higher documentation quality. M/S: Osteoarthritis There is slight enlargement of the spleen. He states he is getting worse and comes in for a checkup. Right Knee: Normal Implement tracking tools to benchmark against best practices, to maintain forward momentum, and to establish timelines for actions, Collaborates in the development of programs, initiatives and workflows, which provide alignment with education for internal customers to support clinical documentation guidelines, Supports, promotes, and encourages Florida Hospital community efforts such as canned food drive, back pack for kids, adopt-a-family, United Way, and all other related activities, Actively participates and supports national, state, and local professional associations, Documentation Improvement team to ensure succession planning. 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 … She states she is less short of breath when walking up stairs this week. as directed on admission and throughout hospitalization, analyzing clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation, Ensure that clinical documentation reflects the level of service rendered to patients in complete, accurate and compliant with the regulations of the Center for Medicare and Medicaid Services, Perform initial charts reviews and assign working DRG within 24 hours of admission, on the working days, Assist in the development of compliant diagnosis/DRG specific queries to aid physicians with proper and precise documentation, Maintain up to date working DRG and has clear strategies to effectuate improved quality of clinical documentation for all the select cases, Regularly participate in scheduled case management meetings and actively exchange information pertaining to clinical documentation, plan of care affecting coding and reimbursement, Take responsibility in addressing medical necessity issues through concurrent review process, initiating compliance with CORE measures before discharge and assisting in follow-up on queries and clarifications to physicians concurrently and retrospectively, Effective oral and written communication skills, with the ability to articulate complex information in understandable terms to all levels of staff, Customer-focused attitude and ability to work proactively and efficiently with appropriate urgency, Effective computer skills, particularly Microsoft Office Outlook, Word, Excel, Ability to work in a matrix-management environment to achieve organizational goals, Ability to establish and manage complex and effective relationships, Excellent analytical and problem-solving skills, At least seven to ten years’ acute hospital clinical experience, Ten plus years of experience in a clinical documentation improvement program, 5+ years of experience doing Clinical Documentation Improvement (CDI), Experience managing people in a CDI setting, Minimum of three years as a lead clinical documentation specialist, Advanced clinical expertise and extensive knowledge of complex disease processes with broad based clinical experience in an inpatient setting, Expertise in MSDRGs, ICD coding and CDI practices required, Expertise in CDI practices and knowledge distribution to multidisciplinary teams, Proficiency with Microsoft Applications, including word processing, spreadsheets and presentation software, Extensive knowledge and experience in reporting software and electronic medical record systems, Maintains working knowledge of Medicare/Medicaid rules and regulations regarding CDI, POA (present on admission), basic coding, as well as current trends and developments in the area of Clinical Documentation Improvement (CDI), Ability to work with senior management, physicians, and medical center staff with various levels of education and experience, Ability to develop and maintain strong, collaborative and supportive working relationships with CDI peers, physicians and other clinical professionals, Must have demonstrated interpersonal, verbal and written communication skills in dealing with multidisciplinary teams and variety of ongoing activities, Knowledge of project management processes and systems, Knowledge of statistical analysis and reporting practices pertaining to quality improvement and program evaluation, Demonstrated organizational, project management skills, Ability to be creative and innovative in a high volume work environment, Ability to lead teams and produce project results within schedule and budget, Ability to plan, organize, motivate, mentor, direct and evaluate the work of others, Ability to provide leadership and influence others, Skilled and experienced in data analysis and qualitative reporting of results, Skill in developing and delivering training and education to clinical, CDI and coding professionals regarding CDI practices, coding and documentation requirements, Demonstrated organizational and critical thinking skills, ability to assess, evaluate and teach, Skilled in adaptability and self-motivation in staying abreast of CDI practices, coding changes and clinical practices, Demonstrated judgment and independent decision making, Valid Registered Nurse license or foreign medical graduate. Every site can have a different CDI plan. Coordinated clinical documentation improvement opportunities for medical staff and allied health professionals. Clinical Documentation Improvement Specialist II Resume. 1. 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. 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 … Cardiovascular: Popliteal is diminished, pedal pulse is normal. 230 Lbs, BMI 34 Temp. Provides facility specific CDI analysis and makes recommendations for process improvement. Left knee for routine 4 views. 11 EXAMPLES 57 11.1 Examples Of Strengths 57 ... (BHRS) policies & procedures, directives, and memos; and the Quality Improvement Program’s interpretation and determination of documentation standards. It’s actually very simple. Hypertension is coded as unspecified for this patient because it is not documented as benign. 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 … This additional information provides a better understanding of how bad the patient feels. discussed all of this over the phone with his daughter and she is in agreement. 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. He is to call me immediately if his fever elevates to 100.5 or greater, Pain with palpation and ROM, No joint problems have a hereditary link. and rales to bilateral lower lobes. it offered. or his cough or SOB worsens during the night. Present the most important skills in your resume, there's a list of typical clinical documentation improvement specialist skills: Acute care hospital clinical RN experience with hospital Case Management experience or CDI experience OR Medical Graduate with CDI experience. According to Denise Van Fleet, a registered health information administrator and HIM program coordinator for Rasmussen College, “CDI is an … SOB, Abnormal chest sounds, Cough, 786.05, 786.7, 786.2 cause the pain. Works with Physician Advisors to address outlier physicians. Provides additional education and guidance to staff when required, Guides, supports and sponsors the Hospital's Clinical Documentation Improvement efforts. 4. up today. While accurate documentation has always been important and critical, changes in the way the healthcare providers are reimbursed over the last few years has brought CDI (clinical documentation improvement) to the forefront. Clinical Documentation Improvement—A Physician Perspective: Insider Tips for getting Physician Participation in CDI Programs. Team members at Allina want to build on their program’s success and further leverage the CDI analytics application. Privacy Policy | Terms & Conditions | Contact Us. Then, paste the image into a word processing program and send it … Physician Education in Clinical Documentation Improvement: Accurately Documenting and Supporting Diagnoses in the Delivery of Medically Necessary and Appropriate Healthcare Marianne Ries, MD, MBA, CPE Revenue Cycle and Institute for Population Health . With physicians to improve t … Recognizing the value of clinical Documentation Improvement workshop s condition knee which is.... Seasonal allergies Responsibility includes one manager who is directly responsible for and supports a total of 40 FTE ’.... Extremities are normal on exam the phone with his friend at River Crossing Assisted Center! 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