CDI Specialist (Hillcrest)

Clinical Documentation Improvement Specialist

Location: Hillcrest HealthCare System (Tulsa, OK)

Employment Type: Full Time

Department: Health Information Management

Reports to: Assistant Vice President, Clinical Documentation Specialist

Who is Ardent?

Ardent Health Services invests in people, technology, facilities and communities, producing high-quality care and extraordinary results. Based in Nashville, Tennessee, Ardent’s subsidiaries own and operate 30 hospitals in six states with more than 26,000 employees including 1,000 employed providers and $4.4B in annual revenue. Ardent facilities exceed national averages in Overall Hospital Quality Star Rating as ranked by the Centers for Medicare & Medicaid Services; 89 percent of its hospitals received a three-star rating or above in comparison with 73 percent of all hospitals ranked Ardent's corporate office has been named "Top Work Places" for Nashville based companies for 5 consecutive years including 2021.

We have an exciting opportunity to join our Health Information Management team in Tulsa, OK as a Clinical Documentation Improvement (CDI) Specialist.

Getting it Right

The Clinical Documentation Improvement (CDI) Specialist works collaboratively with medical staff, nursing staff, other healthcare professionals, and coding staff across the Ardent organization to ensure accurate capture of clinical information through chart review, querying, and education. CDI Specialists review charts for accurate documentation for reimbursement purposes and for designated core measures and quality indicators. The CDI Specialist ensures the overall quality and completeness of medical record clinical documentation; facilitates modifications to clinical documentation through concurrent interaction with physicians, nursing staff, other patient caregivers, and coding staff to support that appropriate reimbursement and clinical severity is captured for the level of service rendered to all inpatients; supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes; and educates all members of the patient care team on an ongoing basis.

The CDI Specialist is responsible for

• Perform medical record chart reviews across all Ardent facilities
• Facilitates concurrent modifications to clinical documentation supporting specificity of services and care provided.
• Demonstrates knowledge of ICD-10 CM and PCS Coding and documentation requirements, clinical documentation requirements and a thorough understanding of policies and procedures.
• Understand facility specific DRG opportunities and differentiate amongst the hospitals within the organization
• Improves the overall quality and completeness of clinical documentation by performing concurrent documentation/coding reviews for all Ardent facilities
• Ensures the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes as well as appropriateness of treatment setting.
• Educates all internal customers, including physicians, nurses and other ancillary personnel, on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies. Creates job aids and queries in support of training initiatives.
• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
• Reviews clinical issues with coding staff, nurses and other healthcare professionals as appropriate to ensure appropriate inpatient technical diagnosis and procedural coding.
• Seeks out opportunities to discuss cases with physicians/provides, including periodic meetings, rounding and/or attending medical staff meetings.
• Maintains a collaborative working relationship with quality, case management and HIM staff across all Ardent facilities
• Inputs activities from concurrent reviews into CDI solution and ensures consistency of data captured.
• Serves as a member of Ardent’s CDI Team providing input relative to documentation improvement processes and resources, and updates Corporate HIM on facility specifc  coding/documentation improvement efforts.

Are you ready?

We are seeking the right blend of experience and education.

Education:

• Licensed Registered Nurse- BSN preferred or RHIA degree
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) is required after being in the role 2 years
• Prefer Associates or Bachelor's degree in Nursing with minimum 3 years acute care experience.
• Prefer Associate or Bachelor’s degree in HIM with minimum of 3 years of recent inpatient coding experience in an acute care setting.

Experience & Requirements:

• Minimum 3 years of experience in coding and/or clinical setting
• Prefer Knowledge of Epic, 3M encoder
• Working knowledge of ICD-10 CM and PCS Coding and Inpatient Prospective Payment System
• Excellent communication skills, both written and verbal, and good Interpersonal skills
• Ability to offer flexibility amongst all Ardent facilities
• Ability to converse with physicians in sometimes difficult training scenarios.
• Ability to conduct brief presentations to facility physicians and leadership.
• Ability to work when physicians are available.

What’s in it for me?

• Fun, energetic people!
• Programs that reach out to our community
• Competitive Paid Time Off program
• 401(k) Retirement Savings
• Competitive Salary
• Comprehensive Medical, Dental and Vision Benefits
• Company provided & Optional Life Insurance
• Healthcare & dependent care flexible spending accounts

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