The Clinical Document Improvement Specialist - (CDS) is responsible for providing CDI program oversight and day to day CDI implementation of processes related to the concurrent review of the clinical documentation in the inpatient medical record of Optum 360 clients' patients. The goal of the CDS oversight and practice is to assess the technical accuracy, specificity, and completeness of provider clinical documentation, and to ensure that the documentation explicitly identifies all clinical findings and conditions present at the time of service.
This position collaborates with providers and other healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely, the clinical treatment, decisions, and diagnoses for the patient. The CDS utilizes clinical expertise and clinical documentation improvement practices as well as facility specific tools for best practice and compliance with the mission/philosophy, standards, goals, and core values of Optum 360.
In this position the CDS will utilize the Optum™ CDI 3D technology that is assisting hospitals to improve data quality to accurately reflect the quality of care provided and ensure revenue integrity.
Our three-dimensional approach to CDI technology, paired with best-practice adoption methodology and change management support, is helping hospitals make a real impact on CDI efficiency and effectiveness.
- Increase in identification of cases with CDI opportunities, with automated review of 100% of records
- Improved tracking, transparency, and reporting related to CDI impact, revenue capture, trending, and compliance
- Improving the specificity and completeness of clinical documentation, resulting in more accurate coding
This position does not have patient care duties, does not have direct patient interactions, and has no role relative to patient care.
Work Location: onsite at Queen's Medical Center, 1301 Punchbowl Street, Honolulu, Hawaii 96813
Primary Responsibilities
- Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the condition and acuity of care provided
- Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity
- Provides expert level leadership for overall improvement in clinical documentation by providing proficient level review and assessment, and effectively articulating recommendations for improvement, and the rational for the recommendations
- Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality
- Performs regular rounding with unit-based physicians and provides Working DRG lists to Care Coordination
- Provides face-to-face educational opportunities with physicians on a regular basis
- Provides complete follow-through on all requests for clarification or recommendations for improvement
- Leads the development and execution of physician education strategies resulting in improved clinical documentation
- Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes
- Ensures effective utilization of Optum® CDI 3D Technology to document all clarification activity
- Utilizes only the Optum360 approved clarification forms
- Proactively develops a reciprocal relationship with the HIM Coding Professionals
- Coordinates and conducts regular meetings with HIM Coding Professionals to reconcile DRGs, monitor retrospective query rates and discuss questions related to Coding and CDI
- Engages and consults with Physician Advisor / VPMA when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process.
- Actively engages with Care Coordination and the Quality Management teams to continually evaluate and spearhead clinical documentation improvement opportunities
Required Qualifications
- For RN candidates, must have a current Hawaii RN license or obtain within 90-days of hire date
- 5+ years acute care hospital clinical RN experience OR Medical Graduate with CDI experience and CDI certification (CCDS, CDIP)
- Experience communicating & working closely with Physicians
- Proficiency in a Windows environment, including Microsoft Word, Excel, Power Point and Electronic Medical Records
Preferred Qualifications
- BSN degree if an RN
- CCDS, CDIP or CCS certification
- Experience in Clinical Documentation Improvement
- CAC experience (Computer Assistant Coding)
The salary for this role will range from $72,800 - $130,000 annually based on full-time employment.