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Clinical Documentation Improvement Specialist

Job Description


Job ID: 1220677
Employment Status: Full-Time
More Information:

Memorial Hospital Belleville is a 222-bed, full-service hospital serving southwest Illinois. Since 2008, it has been designated as a Magnet®-recognized organization for nursing excellence by the American Nurses Credentialing Center. Memorial Hospital Shiloh, a 94-bed, all-private suite hospital was recognized with Magnet status in 2018.

Care Management includes Utilization Management (Utilization Review), Discharge Planning, Social Services, Clinical Outcomes (Care Managers), Discharge Transition Coaches, Nurse Practitioners, and Clinical Documentation Improvement.


Overview


Role Purpose

The Clinical Documentation Improvement Specialist II (CDIS II) uses clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of both inpatient and outpatient medical records reviews to evaluate the clinical documentation of clinical services by identifying opportunities for improving the quality of medical record documentation. This position facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. This position also contributes to content development and provider education (formal and informal), contributes to ongoing service line documentation improvement initiatives, including formal and informal provider education plans, as well as participates in department and organization projects related to documentation improvement.


Responsibilities

  • Actively engages providers and establish relationships to foster shared accountability related to CDI and documentation improvement efforts.
  • Identifies trends, variances, deficiencies, and problems utilizing aggregated data and information as part of the integrated clinical documentation improvement program; performs provider and group level CDI data trend analysis, identifies issues and proposes solutions to leadership.
  • Contributes to ongoing service line documentation improvement initiatives, including formal and informal provider education plans related to clinical documentation improvement.
    Participates in department and organization projects related to documentation improvement.
  • Contributes to content development and potential presentation to key healthcare providers education resulting from the analysis of clinical and financial information from a variety of internal and external sources for the need of accurate and complete documentation in the medical record; interacts and participates in formal and informal education, including content creation, approval facilitation, meeting scheduling/frequency management, participation and possibly content delivery for all assigned service lines.
  • Participates in department and organization projects related to documentation improvement.

  • Minimum Requirements

     

    Degree

  • Associate's Degree
  • - Nursing/Healthcare related

     

    Experience

  • 5-10 years

  •  

    Preferred Requirements and Additional Job Information

     

    Degree

  • Bachelor's Degree
  • - Nursing/Healthcare related
    Benefits Statement

    Note: not all benefits apply to all openings

    -  Comprehensive medical, dental, life insurance, and disability plan options
    -  Pension Plan*/403(b) Plan
    -  401(k) plan
    -  Tuition Assistance
    -  Health Care and Dependent Care Reimbursement Accounts
    -  On-Site Fitness Center (depending on location)
    -  Paid Time Off Program for vacation, holiday and sick time

    *Pension does not apply to Memorial Hospital, Memorial Hospital East, Alton Memorial or Parkland Health Center


    Legal Statement

    The above information on this description has been designed to indicate the general nature and level of work performed by employees in this position. It is not designed to contain or be interpreted as an exhaustive list of all responsibilities, duties and qualifications required of employees assigned to this job.

     

    Equal Opportunity Employer