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+ GENERAL SUMMARY

+ The Clinical Documentation Integrity Specialist is responsible for reviewing inpatient medical records to assess and procure accurate and complete documentation of the patients’ diagnosis and procedures. Reports to department leadership.

+ ESSENTIAL DUTIES AND RESPONSIBILITIES

+ Reviews Inpatient Clinical Documentation, ensuring that physicians’ and clinicians’ documentation, accurately reflect the patient’s conditions, diagnoses, treatments, and interventions, resulting in accurate reimbursement.

+ Reviews to ensure the clinical documentation, reflects the patient’s severity of illness, quality of care and resources used.

+ Provides education to the physicians and ancillary providers regarding accurate, specific and compliant clinical documentation.

+ Acts as a resource for other departments regarding the importance of clinical documentation integrity, and the need to clinically document following the Federal and State regulations.

+ Performs all other duties as assigned.

+ LICENSES AND/OR CERTIFICATIONS

+ Required Licenses and/or Certifications

+ + Current Virginia state license as a Registered Nurse or Registered Nurse holding a valid Compact State license required.

+ Preferred Licenses and/or Certifications

+ + Certified Documentation Improvement Professional (CDIP) or Certified Clinical Documentation Specialist (CCDS) certification or must be credentialed through AHIMA or ACDIS, within two years of start preferred.

+ MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS

+ Required Education and Experience

+ + Registered Nurse -Professional knowledge of nursing theory and practice at a level normally acquired through the completion of an accredited School of Nursing.

+ Preferred Education and Experience

+ + BSN preferred.

+ + Pediatric and or Clinical Documentation or Utilization Management preferred.

+ Required Knowledge, Skills and Abilities

+ + Experience with applying clinical criteria to a medical record review with a Clinical Documentation Integrity focus.

+ + Knowledge of healthcare payment systems, specifically the MS-DRG, Tricare and APR-DRG reimbursement systems.

+ + Ability to form positive and collaborative relationships, with Physicians, HIM colleagues, the Physician Advisor and other hospital staff.

+ + Competent using Microsoft Office Suite, and different Electronic Medical Records.

+ + Requires Strong organizational, clinical critical thinking and analytical skills.

+ Preferred Knowledge, Skills and Abilities

+ + Technical and professional knowledge and skills for clinical operations of the service area, usually acquired through 3 - 5 years’ progressive Clinical/Supervisory experience in a practice setting.

+ WORKING CONDITIONS

+ Normal office environment with little exposure to excessive noise, dust, temperature and the like.

+ PHYSICAL REQUIREMENTS

+ Click here to view physical requirements. (https://www.chkd.org/uploadedFiles/Documents/Employees/Category%20A%20Jobs.pdf )