Clinical Documentation Improvement Specialist (RN) - Mercy Medical Center - (Oshkosh) in Appleton, Wisconsin For Sale

The Clinical Documentation Improvement Specialist (CDIS) facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the health care team to support capture of clinical severity and service intensity for patient populations within the scope of the system CDI program. The CDI Specialist will: o Provide daily clinical evaluation of the medical record including (but not limited to) History and Physical, daily progress notes, diagnostic testing results, consultant reports, ancillary department reports, and treatment plans; o Be responsible for the day-to-day evaluation of documentation by approved authors of medical record documentation in accordance with the hospital's designated clinical documentation policies and procedures; o Communicate with physicians, face-to-face or via clinical documentation query forms in either electronic or written format, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed additional documentation, present opportunities, and educate for appropriate identification of severity of illness; o Communicate with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record; o Using the current version of the International Classification of Disease (ICD) and pertinent medical coding rules and regulations, demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team in a readily understandable manner; o Gather and analyze information pertinent to documentation findings and outcomes for presentation to medical record authors and for use in personal process improvement. BS in Nursing or Registered Nurse 2 years Medsurge experience A total of 10 years acute care experience Current state Registered Nurse license Or BS in Health Information Management 5 years hospital inpatient coding experience A total of 10 years progressive coding experience Active credentials through AHIMA (RHIA/ RHIT; CCS strongly preferred) Applicants with a bachelor degree in a clinically related field with 10 years of acute care experience will also be considered. Skills Required: Proficient in MS Office products including, but not limited to, Excel, Word, and Powerpoint Proficiency in computer usage including database and spreadsheet analysis Working knowledge of Quality Improvement theory and practice Knowledge of federal, state and private payer regulations Company Description: Ministry Health Care is a network of hospitals, clinics, and other health related organizations operating across the central, northern, and northeastern regions of Wisconsin and eastern Minnesota. To meet the needs of the communities we serve, we offer a complete continuum of care through acute and tertiary care hospitals, physician clinics, long-term care and assisted living facilities, home health agencies, hospices, and numerous other programs and services.
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