Clinical Documentation Specialist II CDI

Applies ICD-10 coding guidelines appropriately and has an 85% Working DRG accuracy

Has good working knowledge of all DRG and their structure, as well as CCs and MCCs. Can discern what the impact of a query would be in order to focus efforts efficiently and determine priorities

Reviews all patient records in his/her assigned unit(s) between 24-48 hours of inpatient admission and subsequently beween 2-3 days until discharge, as needed. Manages approximately 16-20 charts daily

Recognizes opportunities for documentation improvement by utilizing sound clinical reasoning and critical thinking skills, as well as coding concepts

Formulates clinically credible queries to physicians and achieves a response rate and agree rate above 85% respectively.

Mantains excellent rapport and working relationship with physicians, residents, physician assistants, nurse practitioners, nurses, case managers and other healthcare providers

Mantains query rate of 25-35% of all patient records reviewed

Follows up on all pending queries on a daily bais until answered and monitors. Manages the Epic query workqueues as well as the 3M 360 pending queries swim lanes regularly

Has good command of 3M 360 Encompass software and maintains an accurate data input of patient's working DRG and baseline DRG. Records daily review notes and all other notes required within the sofware accurately.

Responsible for retrospective reviews for quality and revenue projects as assigned

Properly documents query narrative and notes the expected query response and the actual response including date and location of response in the medical record (what and where).

Responsible for mentoring and training new employees in conjuction with department Manager

Reviews the mismatch report periodically to ensure working DRGs are optimal and addresses any discrepancies with HIM coding staff in an effective and timely manner.

Supports manager in reconciliation of monthly query reports and other financial reports as needed

Works individual monthly financial report to ensure accounts with financially impacting queries have the proper baseline DRG and that final DRG and working DRG match to ensure reporting is optimal

Reports accounts with unaswered queries that would have otherwise impacted DRG weight for tracking.

Provides suport to Rehab team by reviewing potential rehab admissions to ensure they meet CMS compliance criteria and queries Rehab physicians as needed to include supporting diagnoses. Evaluates rehab visits for potential tier improvements by querying physicians for potential qualifying diagnoses.

R.N. or Medical Graduate

R.N. Certified preferred; Medical School Graduate; Bachelor's Degree