Clinical Documentation Improvement Specialist - Nuvance Health
Nuvance Health has a network of convenient hospital and outpatient locations — Danbury Hospital, New Milford Hospital, Norwalk Hospital and Sharon Hospital in Connecticut, and Northern Dutchess Hospital, Putnam Hospital Center and Vassar Brothers Medical Center in New York — plus multiple primary and specialty care physician practices locations, including The Heart Center, a leading provider of cardiology care, and two urgent care offices. Non-acute care is offered through various affiliates, including the Thompson House for rehabilitation and skilled nursing services, and the Home Care organizations.
Responsibilities: 1. Reviews inpatient medical records for identified payer population as directed on admission and throughout hospitalization. Analyze clinical status of patient, current treatment plan and past medical history and capture accurate DRG assignment, SOI, ROM 2. Identifies issues requiring clarification or additional information in the clinical documentation and initiates communication with the appropriate physician or other care provider through compliant query practice 3. Works with CDDI lead to maintains an open and collaborative working relationship with the patient care team, physician champions, and care coordination, denial management, quality and HIM coding staff 4. Participates in CDI team meetings to discuss difficult cases, questions and performance improvement strategies 5. Accurately identifies and reports outliers to Lead CDI and or Manager of CDI program 6. Maintains working knowledge of official ICD-10 and documentation guidelines 7. Assists in resolving inconsistent, conflicting and/or ambiguous documentation through compliant query practice 8. Ensures the query verbiage is in no way leading or suggestive in tone and is supported by the documentation in the record to include clinical indications and treatment provided.
Any one of these credential is acceptable: RN (BSN or MSN), PRN, MD (local or International medical graduate), PA and or RHIA
One of the following certification upon hiring, CDIP, CCDS or acquire within 6 months of hiring
Experience working in inpatient setting for 3 years, 5 years is a plus
Experience with clinical documentation integrity and reportable quality data measures (PSI, HAC)
Have worked in large health system with multiple acute care hospitals
Location: Norwalk-34 Maple St
Work Type: Full-Time
Standard Hours: 40.00
Work Schedule: Day 8
Work Shift: 8 am - 4:30 pm