Clinical Documentation Improvement Specialist

About Xtend Healthcare
Xtend Healthcare is a revenue cycle management company focused exclusively on the healthcare industry. The company's services range from full revenue cycle outsourcing, A/R legacy cleanup and extended business office to coding and consulting engagements. As part of Navient (Nasdaq: NAVI), Xtend taps the strength and scale of a large-scale business processing solutions company. Learn more at www.xtendhealthcare.net

THIS POSITION IS HYBRID ( 3 DAYS/WEEK ON-SITE AT MT. SINAI HOSPITAL, IN CHICAGO, IL./REMOTE 2 DAYS/WEEK)

The Clinical Documentation Improvement Specialist (CDIS) is responsible for the concurrent and retrospective (when applicable) review of medical records to assure appropriateness of care, accuracy of documentation, validation of severity of illness and quality of services provided.   The CDIS will audit charts for appropriateness of admission, continued stay, compliance to hospital metrics and appropriate documentation based on diagnosis and severity of illness.  The Quality CDIS will interact with physicians, nurses and other professionals regarding documentation and actively participate in team meetings to improve physician and clinical staff chart documentation.   Patient charts not meeting approved guidelines will be selected for peer review and follow-up.

The CDIS must exhibit expertise in all aspects of health information management with knowledge and working knowledge of coding (ICD-10-CM & PCS, CPT, MS-DRGS, APRG-DRGs, HCCs) for acute care hospitals, skill nursing facilities, swing beds, hospice, and inpatient rehab facilities.   A high level of knowledge of physician specialty medical practices is also a plus. Understanding and communicating differences between Medicare Part A and Part B guidelines and how they impact MS-DRGs and APR-DRGs is required. 

JOB SUMMARY:

1.   Applies the skills necessary to concurrently/retrospectively review (initial & extended stay) charts, improve documentation based on diagnosis and clinical findings.

2. Generates reports internally on required functions.   

3.  Effective and appropriate communication with physicians and nurses. 

4.  Participates in internal and external Team Meetings. Demonstrating professionalism when communicating with CDI and HIM staff in resolving discrepancies.

MINIMUM REQUIREMENTS:

• Associate degree (Nursing degree or specialized HIM degree (RHIA or RHIT) HIM Professional coder credentialed or credential eligible.)

• Three (3) years’ experience in the CDI and/or health information management area of healthcare.  This should include hospital with physician practice.  (Additional equivalent education above the required minimum may for the required level of experience)

• Working knowledge of ICD10 CM & PCS, CPT, MS-DRGs, APR-DRGs

• Electronic health record (EHR) expertise, including knowledge of a variety of vendors.

• Must be credentialed through AHIMA and/or ACDIS at a minimum.

PREFERRED QUALIFICATIONS:

• An understanding of healthcare billing practices and compliant claims preparation for both governmental and commercial payers.

• Knowledge of HCC’s is preferred

• Experience with encoders; experience with CAC software

• Experience with Case Management, Utilization Review

• A plus if: CCS, CCDIS, nationally recognized ICD-10-CM and PCS trainer National HIM certifications from the AAPC or AHIMA, or CCDS from ACDIS

• Working knowledge of CDI “best practices.”

• Able to interact positively with clients and understand their needs in the HIM and medical records of healthcare.