Provides remote clinical documentation integrity (CDI) support to the Health Ministry (HM) CDI programs as part of the System Office CDI Float Pool. Utilizes advanced coding and/or clinical expertise to direct efforts toward the improvement and integrity of clinical documentation.
Responsible for reviewing and/or auditing medical record clinical documentation to support the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services rendered to all patients. Audits HM CDSs for query compliance, workflow and missed documentation opportunities. Trains end users in the use of CDI system software, standards, and workflow.
ESSENTIAL FUNCTIONS
Knows, understands, incorporates, and demonstrates Trinity Health's Mission, Vision, and Values in behaviors, practices, and decisions.
Demonstrates understanding of and facilitates appropriate clinical documentation, to ensure that the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services provided are accurately reflected in the health record.
Conducts clinical documentation chart reviews and queries providers as appropriate to support RHMs staffing needs. Reviews may be conducted on site or remotely.
Follows HM CDI Program workflow and processes and communicates with local CDI Team to support local operations.
Communicates with physicians and other members of the healthcare team at the HM regarding clinical documentation as part of local CDI Team assignment.
Audits medical records, queries, CDS and coder assigned codes, CDI software entries, etc., as requested to provide feedback to the HMs for improvement opportunities.
Trains end users in the use of CDI system software, standards, and workflow.
Provides documentation education to providers and members of healthcare team at the RHM as part of CDI Team assignment or as requested.
Demonstrates ability to quickly learn and master the various CDI technology applications, systems and workflows in place across the enterprise.
Provides expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgment and serves as a professional role model by demonstrating desirable practice behaviors.
Assists the System Office Clinical Documentation Manager with all aspects of the CDI program across the system including data collection and maintenance of the CDI Dashboard.
May develop educational content for providers and CDSs on CDI workflow and processes, CDI and Physician software systems, and documentation and coding guidelines as requested.
Performs other duties as assigned by leadership.
Maintains a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, Trinity Health’s Organizational Integrity Program, Standards of Conduct, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
Hourly pay range: $40.6207 - $60.9311
MINIMUM QUALIFICATIONSMust possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) or an Advanced degree in nursing (NP/APN) or Physician Assistant (PA). In the absence of a college degree, must have 3 or more years’ experience as an inpatient coder or clinical documentation specialist.
At least two (2) years acute care inpatient clinical documentation specialist experience required.
Preferred certification or licensure includes one or more of the following:
Current Registered Nurse License,Registered Health Information Administrator (RHIA),Registered Health Information Technician (RHIT),Certified Coding Specialist (CCS),Certified Clinical Documentation Specialist (CCDS)Certified Documentation Improvement Professional (CDIP).Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), or as an inpatient coder preferred. Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills required. Ability to educate all members of the healthcare team related to clinical documentation.
Experience with databases, spreadsheet software and presentation software preferred.
Must be comfortable operating independently in a collaborative, shared leadership environment.
Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health.
PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONSMust be able to set and organize own work priorities and adapt to them as they change frequently. Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles.
Must possess the ability to comply with Trinity Health policies and procedures.
Must be able to spend majority of work time utilizing a computer, monitor, and keyboard.
Must be able to perform some lifting and/or pushing/pulling up to 20 pounds.
Must be able to work with interruptions and perform detailed tasks.
Must be able to work on different projects simultaneously and coordinate work to meet deadlines.
Requires the ability to concentrate and read for long periods of time.
Involves a wide array of physical activities, primarily walking, standing, balancing, sitting, squatting, and reading. Must be able to sit for long periods of time.
The above statements are intended to describe the general nature and level of work being performed by persons assigned to this classification. They are not to be construed as an exhaustive list of duties so assigned.
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.