Job Description

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The Clinical Documentation Specialist 3 performs high-level, complex, secondary case reviews to facilitate and obtain appropriate provider documentation for clinical conditions or procedures to reflect the severity of illness, expected risk of mortality, accuracy of patient outcomes, and complexity of patient care. The Clinical Documentation Specialist 3 serves as a key resource for CDI/Coding/Quality, and works in collaboration with CDI & quality leadership, CDI specialists, coders, quality analysts, providers, and other members of the healthcare team to ensure accurate, high-quality clinical documentation to support UHealth initiatives.

• Ensures accuracy, completeness, and quality of clinical information used for measuring and reporting physician and hospital outcomes.

• Performs high-level, complex, timely secondary case reviews concurrently and retrospectively to identify potential gaps or opportunities to facilitate improved provider documentation. 

• Ensure clinical documentation accurately reflects the level of care rendered, severity of illness, risk of mortality, and clinical validation (in compliance with government and other regulations).

• Applies advanced knowledge of CMS star rating, Vizient, and US News and World Report risk-adjustment systems to identify clinical documentation improvement opportunities.  Completes quality reviews focused on CDI quality elements, such as Mortality, Hospital Acquired Conditions (HAC), and other publicly reported patient quality or safety metrics (i.e. AHRQ Patient Safety Indicators).

• Identify trends and key areas for improvement in querying coding, and documentation integrity. Demonstrates proficiency with ICD-10-CM/PCS, APR DRG, and MS DRG by providing information regarding clinical documentation opportunities, coding, and DRG issues, as well as performance improvement methodologies.

• Recognizes opportunities for documentation improvement using strong critical-thinking skills and sound judgment in decision-making, keeping integrity and compliance at the forefront of considerations in addition to outcomes, reimbursement, and regulatory requirements.

• Facilitates high-quality documentation by utilizing queries that are effective, clear, concise, and compliant in accordance with the latest AHIMA/ACDIS Query Practice Brief. 

• Makes recommendations for possible refinement of principal diagnosis, secondary diagnoses, and/or procedures based on clinical data to facilitate appropriate DRG assignment. Records review findings and other data elements accurately into CDI Software and other data mechanisms to support data integrity for reporting. Effectively and appropriately communicates and collaborates with providers, HIM/coding, quality, CDI, and other members of the healthcare team.

• Assists with concurrent and retrospective CDI case reviews, quality audits, and education as deemed necessary by CDI Leadership.

• Works independently; demonstrates effective time management and prioritization of tasks.  Participates in meetings, including providing feedback and identifying trends and opportunities, presentations for educational opportunities, and any other needs identified by the CDI leaders.

• Assumes responsibility for professional development through participation at workshops, conferences, and/or in-services and maintains appropriate records of participation.

• Participates in departmental and organization projects, task forces, and/or committees as needed. Complies with and ensures adherence to HIPAA and Code of Conduct policies.

• Adheres to University and unit-level policies and procedures and safeguards University assets.

This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.

CORE QUALIFICATIONS                                                                                                         

Education:

Four (4) Year/Bachelor's Degree Required RN in state of FL; BSN/BS/BA in related field Required; Graduate Degree Preferred; Healthcare Administration, Informatics, Nursing, Leadership, Education or related field;

FMG (MD) with extensive clinical and CDI experience will also be considered.

Certification and Licensing:

Maintains current State of Florida RN license or valid eNLC multistate RN license; Basic Life Support (BLS) from the American Heart Association.

RHIA or RHIT Certification

Must maintain current one of the following:

Certified Documentation Specialist (CCDS) by the Association of Clinical Documentation Improvement Specialists

Clinical Documentation Improvement Professional (CDIP) by The American Health Information Management Association

Certified Professional Coder (CPC) by the American Academy of Professional Coders (AAPC)

Certified Coding Specialist (CCS)

Experience:

Minimum 5 years of relevant experience.

Three (3) years of clinical experience in hospital setting with extensive clinical knowledge and understanding of pathology/physiology.

Three (3) years previous acute care clinical documentation improvement specialist or quality leadership experience.

Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting.

Thorough knowledge of ICD-9-CM, ICD-10-CM/PCS, APR DRG and MS DRG, Mortality, PSI and HAC required.

Knowledge, Skills and Attitudes:

• General knowledge of office procedures and operations

• Skill in data entry with minimal errors

• Ability to accurately prepare and maintain records, files, reports and correspondence

• Ability to communicate effectively in both oral and written form.

• Ability to handle difficult and stressful situations with professional composure.

• Ability to maintain effective interpersonal relationships.

• Ability to understand and follow instructions.

The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.

UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for.

The University of Miami is an Equal Opportunity Employer - Females/Minorities/Protected Veterans/Individuals with Disabilities are encouraged to apply. Applicants and employees are protected from discrimination based on certain categories protected by Federal law. Click here for additional information.

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