We are seeking a clinical documentation improvement specialist at BJC HealthCare!
If you have a CDI or ICU nursing background, check this position out today!
Overview
Barnes-Jewish Hospital at Washington University Medical Center is the largest hospital in Missouri and is ranked as one of the nation's top hospitals by U.S. News & World Report. Barnes-Jewish Hospital's staff is composed of full-time academic faculty and community physicians of Washington University School of Medicine, supported by a house staff of residents, interns, fellows and other medical professionals. Recognizing its excellence in nursing care, Barnes-Jewish Hospital was the first adult hospital in Missouri to be certified as a Magnet Hospital by the American Nurses Credentialing Center.
Preferred Qualifications
Role Purpose
The Clinical Documentation Improvement Specialist I (CDIS I) uses clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of both inpatient and outpatient medical records reviews to evaluate the clinical documentation of clinical services by identifying opportunities for improving the quality of medical record documentation. This position facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient.
Responsibilities
Reviews clinical documentation to facilitate the accurate representation of the severity of illness, expected risk of mortality, and complexity of care by improving the quality of the physician?s clinical documentation.
Utilizes hospital coding code set, policies and procedures, federal and state coding reimbursement guidelines, and application of the Coding Clinic Guidelines to assign working diagnosis-related groups (DRG); review patient records throughout hospitalization that have been identified as focus DRG by regulatory agencies or the facility to ensure the codes are reported at the highest specificity.
Initiates physician interaction when abnormal ancillary test findings, ambiguous, missing or conflicting information is in the medical record, through the physician query process and/or participation in rounding with the physicians by requesting additional documentation for correct coding and compliance necessary for accurate reflection of CMI, LOS, and optimal resource utilization.
Partners with other healthcare disciplines and HIMS coding staff to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to reconcile the working and final DRG, severity of illness, risk of mortality and quality outcomes.
Initiates medical record review within 24 to 48 hours of admission; sytematically monitors the targeted medical records within at least 48 hours (unless otherwise indicated) to determine compliance to established documentation standards; conducts follow-up reviews to ensure points of clarification have been addressed/documented in the medical record.
Minimum Requirements
Education
Nursing Diploma/Associate's
- Nursing
Experience
2-5 years
Licenses & Certifications
RN
Preferred Requirements
Education
Bachelor's Degree
- Nursing
Experience
5-10 years
Supervisor Experience
No Experience
Benefits and Legal Statement
BJC Total Rewards
At BJC we’re committed to providing you and your family with benefits and resources to help you manage your physical, emotional, social and financial well-being.
Comprehensive medical, dental, vison, life insurance, and legal services available first day of the month after hire date
Disability insurance* paid for by BJC
Pension Plan*/403(b) Plan funded by BJC
401(k) plan with BJC match
Tuition Assistance available on first day
BJC Institute for Learning and Development
Health Care and Dependent Care Flexible Spending Accounts
Paid Time Off benefit combines vacation, sick days, holidays and personal time
The above information on this description has been designed to indicate the general nature and level of work performed by employees in this position. It is not designed to contain or be interpreted as an exhaustive list of all responsibilities, duties and qualifications required of employees assigned to this job. Equal Opportunity Employer
BJC HealthCare is one of the largest nonprofit health care organizations in the United States, delivering services to residents primarily in the greater St. Louis, southern Illinois and southeast Missouri regions. With net revenues of $5.5 billion and more than 30,000 employees, BJC serves patients and their families in urban, suburban and rural communities through its 15 hospitals and multiple community health locations. Services include inpatient and outpatient care, primary care, community health and wellness, workplace health, home health, community mental health, rehabilitation, long-term care and hospice.
BJC is the largest provider of charity care, unreimbursed care and community benefits in the state of Missouri. BJC and its hospitals and health service organizations provide $785.9 million annually in community benefit. That includes $410.6 million in charity care and other financial assistance to patients to ensure medical care regardless of their ability to pay. In addition, BJC provides additional community benefits through commitments to research, emergency preparedness, regional health care safety net services, health literacy, community outreach and community healt...h programs and regional economic development.
BJC’s patients have access to the latest advances in medical science and technology through a formal affiliation between Barnes-Jewish Hospital and St. Louis Children’s Hospital with the renowned Washington University School of Medicine, which consistently ranks among the top medical schools in the country.
