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Job Description – Clinical Documentation Improvement Specialist

|Job Title |Clinical Documentation Improvement Specialist |

|Job Code |413033 |

|FLSA Status | Exempt | Non-Exempt |

Organizational Culture: The University of Kansas Hospital's mission is "To Lead the Nation in Caring, Healing, Teaching and Learning." We are committed to hiring individuals who demonstrate both a strong fit with our team-based and patient-focused culture and who have the skills, knowledge, and experience to succeed in their chosen position. Individuals selected for employment are those who will help us advance our mission and who exemplify our values through their personal and professional actions.

List and describe essential functions of the job in concise, comprehensive statements. Address what the jobholder does to achieve the job’s main purpose.

Note: These statements are intended to describe the essential functions of the job and are not intended to be an exhaustive list of all responsibilities, skills and duties and may vary dependent upon your department or unit. Other duties may be assigned as required.

JOB SUMMARY

The Clinical Documentation Specialist (CDS) will review inpatient medical records as directed on admission and throughout hospitalization for completeness and accuracy for severity of illness (SOI) and risk of mortality (ROM). The CDS will ensure effective and appropriate communication with the attending physicians, residents, fellows, PAs and APNs either verbally or in written methodology to suggest additional and/or more specific documentation. The CDS works closely with the HIM coding staff to assure documentation of discharge diagnosis(es) and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care.

Requirements include a Bachelor’s degree in Nursing, or foreign medical graduate with CDI certification as CCDS and/or CDIP. A minimum of 3-5 years clinical experience in acute care setting and critical care experience preferred. Previous Clinical Documentation or Case Management experience desirable. You must have a current RN licensure in the State of KS or be eligible for KS licensure. Will accept foreign medical graduate (MD degree) with CDI certification of CCDS and/or CDIP in lieu of Kansas RN license.

RESPONSIBILITIES

|Responsibilities |

|Responsible for concurrent review of the clinical documentation in the medical records and query of the medical staff and other care |

|givers as necessary via prompters/verbal communication to obtain accurate and complete documentation which appropriately supports the |

|severity of patient illness and risk of mortality |

|In collaboration with the physician, nurse, patient care coordinator, ancillary departments, and HIM coder, identifies and records |

|principle diagnoses, secondary diagnoses, and procedures. |

|Conducts initial concurrent review and ongoing re-review for all selected admissions to initiate the tracking process, document findings |

|on the CDS worksheets, and identify other key pathway or quality indicators as appropriate. |

|Utilizes clinical knowledge to identify need to clarify documentation in records, and utilizes strong commination skills with physician, |

|physician extender, case manager, utilization review, nurse or other healthcare professionals, utilizing appropriate tools to capture |

|needed documentation. Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports |

|the accurate patient’s severity of illness and risk of mortality. |

|Utilizes monitoring tools to track the progress of the program, through interpretation of on-site reports, monitoring reports and data. |

|Shares findings with identified staff. Identifies areas that need focuses review through report analysis. Serves as a resource to |

|physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment. |

|Reviews coder feedback on completed worksheets and individual CDS tracking system reports as a means of continuous self-evaluation; |

|discusses any issues or concerns with the CDI Supervisor. |

|Educates Physicians and Staff regarding severity of illness and risk of mortality documentation. |

|Collaborates with Physicians, Mid-level Providers, CDI Staff, and HIM Coders as well as works directly with individuals and departments |

|where documentation improvement opportunities exist. |

| |

|Coordinates data and documentation compliance and collaborates on all aspects of the program to improve clinical documentation. |

| |

|Serves as an effective communicator of the clinical documentation improvement program’s vision and goals. Expressed ideas clearly and |

|effectively (gaining agreement and/or understanding), by adjusting language, terminology, and style to the characteristics and needs of |

|the audience as well as the venue for the communication. Effectively administers training sessions to new House Staff, Attending Staff, |

|Nursing and Ancillary personnel. |

| |

|Develops and participates in presentations on clinical documentation improvement. |

| |

|Demonstrates competence in the areas of critical thinking, interpersonal relationships and technical skills. |

| |

|Manages his/her organizational responsibilities in a way that supports the achievement of departmental goals. Works effectively with |

|others in the management team to accomplish organizational goals and to identify and resolve problems. Skillfully administers, directs |

|and allocates all organization resources. |

| |

|Uses appropriate interpersonal styles and methods to develop a unit/team-wide spirit and intra-team and inter-team cooperation. |

| |

|Ensures confidentiality of all data and security of Protected Health Information as it relates to HIPAA requirements. |

BEHAVIORAL COMPETENCIES

Key competencies required to perform essential functions of the job - Foundational level

|ACCOUNTABILITY – |- Takes personal responsibility for completing assigned activities and seeks new opportunities to provide|

|Ownership, Initiative, Trust |high-quality work/service; looks for ways to improve individual performance |

|and Respect, Continuous |- Is clear about daily tasks and shows a flexible, proactive approach to accomplishing responsibilities |

|Learning/ Improvement |in the face of changing situations (e.g. patient emergencies) |

| |- Shows respect in every interaction and builds trust; demonstrates adherence to code of conduct |

| |- Shows willingness to learn new technologies, tools or systems, and is eager to gain new skills |

|CUSTOMER FOCUS - |- Understands personal and practical needs of all customers and takes appropriate action to meet |

|Customer Expectations and |expectations for quality care and/or service |

|Needs, Service Improvement, |- Has self awareness of own behaviors; makes changes in behavior to improve the service experience; is |

|Cross-functional Collaboration |aware of how personal actions affect the customer experience; adjusts personal behaviors as needed to |

| |meet or exceed customer expectations |

| |- Demonstrates the ability to work effectively within and across work units to deliver the best customer |

| |experience |

|PLANNING AND DECISION MAKING – |- Plans daily routine to properly organize tasks and demonstrates the flexibility to meet immediate |

|Planning and Organization, |customer needs effectively and efficiently |

|Problem Solving, Time |- Proactively asks open-ended questions to clarify and resolve underlying issues; escalates issues |

|Management, Effective Use of |promptly and responsibly as necessary |

|Resources |- Allocates time appropriately to effectively handle multiple priorities and varying workload |

| |- Demonstrates stewardship through the identification and appropriate use of available resources (time, |

| |equipment and supplies) |

|COMMUNICATION – |- Listens well, shows a positive attitude and modifies tone and delivery to effectively meet the needs of|

|Interpersonal Skills, Effective|the customer |

|Communication, Managing Crucial|- Demonstrates self-awareness and gathers thoughts before speaking to deliver clear messages that are |

|Conversations |easily understood by others |

| |- Understands needs of others and willingly takes the H.E.A.T. by remaining calm and positive under high |

| |stress situations |

|RELATIONSHIP MANAGEMENT AND |- Is approachable, builds rapport, and uses formal and informal networks to facilitate achievement of |

|TEAMWORK – |departmental and organizational goals |

|Building Productive |- Willingly shares information, materials and know-how to contribute to and achieve common objectives |

|Relationships, Knowledge |- Works as a team player in a diverse workforce and looks for ways to improve interactions with all |

|Sharing, Collaboration |co-workers, contributing to a welcoming and helpful environment |

POPULATION SERVED

|Population Served |Age of Patient Population Served |

| Patient with exceptional communication needs | Neonate (birth - 28 days) |

|Patient with diverse culture/language (e.g. in Spanish and Sign) |Infant (29 days – less than 1 year) |

|Patient with diverse religious backgrounds |Pediatric (1 - 12 yrs) |

|Patient with psycho-social needs |Adolescent (13 – 17 yrs) |

|Patient with physical disabilities |Adult (18 – 64 yrs) |

|All Populations |Geriatric (65 yrs & older) |

|Does not have patient contact |Non-age Specific Task (N/A) |

JOB REQUIREMENTS

Indicate the minimum requirements to perform the essential functions of the job – minimum education and/or experience, any significant physical demands aspects of work environment conditions.

A. Education and/or Relevant Experience/Qualifications

| |Required |Preferred |

|Credential required: |RN license in Kansas |Previous Clinical Documentation, Case |

|Education |Bachelor’s Degree in Nursing for RN’s. |Management or Critical Care experience |

|Certificate, license or registration |3-5 years clinical experience in an acute care | |

|Experience |setting | |

| |Will also accept foreign medical graduate (MD) with | |

| |CDI certification of CCDS and/or CDIP in lieu of | |

| |Kansas RN license. | |

|Primary source of verification |Kansas State Board of Nursing, or CCDS and/or CDIP | |

| |certification for foreign medical graduates with MD. | |

|Literacy requirements (read, write and |Read, write and speak English | |

|speak English) | | |

|Language requirements |Read, write and speak English | |

|Others (Driving, computer skills, etc.) |Superior oral and written communication skills | |

B. ADA Physical Demands

|How much on the job time is spent on the following physical activities? | |Does this job require that force be exerted or weight be |

| | |lifted? |

|Physical Activities |Amount of Time | |Pounds of Force to Push or |Amount of Time |

| | | |Pull | |

| |None |

| |Distance vision (clear vision at 20 feet or more) |

| |Color vision (ability to identify and distinguish colors) |

| |Peripheral vision (ability to observe and area that can be seen up and down or to the left and right while eyes are fixed on a |

| |given point) |

| |Depth perception (three-dimensional vision, ability to judge distances and spatial relationships) |

| |Ability to adjust focus (ability to adjust the eye to bring an object into sharp focus) |

| |No special vision requirements |

Does this job have any special hearing requirements? Please specify.

| |Specify hearing requirements:___________________________________________ |

| |No special hearing requirements |

C. Work Environment

How much on the job time is spent in the following conditions? Does this job have exposure to the following conditions?

|Environmental Conditions |Amount of Time | |Environmental Conditions |

| |Non|Under 1/3 |

| |e | |

Prepared byName:      Date      EmployeeName:      Date      Title:      Signature:      Department approval Name:      Date      SupervisorName:      Date      Title:      Signature:      HR approvalName:      Date      Title:      

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