The Clinical Documentation Improvement (CDI) Educator provides enterprise-wide education and training to CDI staff, medical providers and ancillary staff on effective, compliant clinical documentation. This role facilitates consistent, accurate, optimal documentation by providing both formal and informal educational programs. The CDI Educator develops, implements and coordinators a system-wide formal CDI orientation program, including competency standards. The incumbent will work with the analytic team, leadership and the coding department to assess documentation gaps and formulate appropriate CDI educational tools to included, but not limited to, power point presentations, memos, and documentation tips sheets.
The CDI Educator will apply teaching/learning principles in establishing an overall educational program related to effective clinical documentation for, and in collaboration with, CDI staff, physicians and the health care team. This associate will provide education for all members of the patient care team on issues relating to clinical documentation. Also, the CDI Educator will act as a resource to the CDI team, Coding Integrity, Clinical Appeals Team, Compliance, and clinical providers on optimal clinical documentation.
- Develops, implements and maintains formal and informal educational programs, including creating the CDI orientation program, related to documentation improvement opportunities, coding and reimbursement issues, as well as performance improvement methodologies for internal customers and physicians. Analyzes and compiles accurate and complete data for statistical reporting and educational presentations, as needed.
- Communicates and interacts with physicians and clinical staff via informal verbal communication, the use of written communication tools, and formal educational presentations. Utilizes research, analytic data and observations to provide recommendations to improve the overall quality and completeness of clinical documentation.
- Analyzes, summarizes and documents outcomes of documentation improvement process for re-evaluation of ongoing program revisions. Participates as a member of work groups related to clinical documentation, utilization and compliance, if required.
- Establishes cooperative and multidisciplinary relationships with physicians, coding staff and other health team members. Acts as a resource to the CDI department and health team members related to optimal documentation, educational needs and successful problem resolution.
- Familiarity with MS-DRG/APR-DRG's and Inpatient Prospective Payment System (IPPS), including new CMS guidelines of key elements including clinical documentation of what constitutes an inpatient admission. Along with familiarity and the ability to effectively communicate the use various coding systems and Official Coding Guidelines.
- Performs concurrent and retrospective reviews of the medical record (as needed), utilizing evidence-based knowledge, protocols and criteria. Facilitates modifications to support clinical documentation of health team members to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a focus on physician documentation, inpatients and DRG payers. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart.
- Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart. In conjunction with CDI leadership, tracks response to clinical documentation and trends completion of the process, e.g. DRG database and/or worksheets (as needed).
- Maintains and enhances current medical, coding and CDI knowledge via participating in continuing education offerings.
- Effective ability and willingness to communicate benefits of complete and accurate documentation to physicians relating to their daily practice of medicine.
POSITION SPECIFIC COMPETENCIES
- Demonstrates knowledge of DRG payer issues for documentation opportunities, clinical documentation requirements, coding standards as applied to medical record documentation and compliance requirements. Demonstrates working knowledge of MS and APR DRG's and intensity of service criteria.
- Develops and maintains a close working relationships with physicians, coders, clinical appeals team, nursing staff, health information management, quality and managed care staff, as well as other ancillary departments responsible for clinical documentation.
- Demonstrates enhanced knowledge of anatomy and pathophysiology to facilitate the increased need for granularity and specificity within the clinical documentation with the transition to new coding systems. Demonstrates the ability to accurately utilize and provide instruction related to coding guidelines, software systems and resource material.
- Improves the overall quality and completeness of clinical documentation through the application of evidence-based knowledge, analysis, in-depth review, interpretation, identification of opportunities, communication and consistent follow-up and evaluation of concurrent and retrospective (as required) medical record documentation. Interacts primarily with, but not limited to, physicians, nursing staff, other patient caregivers and health information coding staff to capture appropriate reimbursement and clinical severity for the level of service rendered to all patients, with a focus on DRG-based payers.
- Works with Clinical Data Analyst to quantify complete and accurate clinical documentation and utilization, focusing on DRG payers.
- Self-directed, independent decision-making, analytical teaching and articulate communication skills, both verbal and written.
- Bachelor's degree in Nursing or other related fields with strong knowledge of clinical documentation, i.e. Physician Assistant, Nurse Practitioner, or International Trained Physician
- Master's degree preferred
- 3-5 years' experience as a Clinical Documentation Specialist
- 2-5 years' experience in formulating and presenting information on clinical documentation to educate physicians and clinical staff
- 3-5 years' experience in an acute hospital setting
- Experienced educator with a strong understanding of the requirements for clinical coding and billing according to the rules of Medicare, Medicaid, and commercial payers preferred
C. Licenses, Registrations, or Certifications
- ICD training certification
- Certified Clinical Documentation Specialist (CCDS) issued by the Association of Clinical Documentation Improvement Specialists (ACDIS) or Certified Documentation Improvement Practitioner (CDIP) issued by The American Health Information Management Association (AHIMA). Eligible candidates required to obtain within one year of hire.
- Current licenses according to state and federal requirements (if applicable)