Responsible for utilizing their clinical/nursing knowledge, deep knowledge of chronic and complex illness, and understanding of current CMS coding guidelines, conventions and AHA coding clinics to improve the overall quality and completeness of the patient medical record
Performs pre-visit and retrospective reviews of ambulatory clinical documentation to ensure accurate depiction of the true complexity of the patient. This includes compliant documentation to support the capture or Hierarchical Condition Categories (HCC), ICD-10-CM accuracy and specificity, and medical necessity.
Collaborates with multidisciplinary teams to develop analytic strategies to assess the quality of Outpatient CDI program (with HCC & RAF Scores)
Pulls data from multiple sources and produces reports related to Outpatient CDI, quality, safety, throughput, access, and value on both a recurring and ad hoc basis, to meet the needs of a diverse set of customers.
Communicate with Physicians, Medical Management leaders, Coding and Risk Adjustment Operations, PHSO Medical Director, coders, compliance specialists and/or clinical documentation analysts regarding documentation clarification and accurate coding, as needed.
Facilitates appropriate modifications to clinical documentation to accurately reflect patient severity of illness and risk through extensive interaction with physicians, case management staff, nursing staff, other patient caregivers, and coding staff. With Director and Supervisor’s guidance, collaborates with coding staff to develop standard coding guidelines, policies and procedures.
Demonstrates knowledge of documentation requirements and coding guidelines that pertain to outpatient diagnosis coding to accurately reflect the complexity and medical necessity of the visit.
Routinely provides education to physicians, advanced practice providers and other key healthcare providers regarding the need for accurate, specific, and complete clinical documentation in the patient's medical record
Delivers provider specific metrics and coach providers on problem list and RAF gap closing opportunities as needed.
Participates in meetings, select committees, and educational programs as needed.
What You Will Need:
Education and Experience Required:
Nursing degree with comprehensive knowledge and understanding of chronic and acute disease conditions, management, and treatment
Comprehensive knowledge and understanding of utilization management criteria (i.e.: InterQual, Milliman)
Minimum of two years’ experience with, modeling, and report development
Licensure, Certification, or Registration Required:
Nursing licensure as a Licensed Practical Nurse (LPN) in good standing with the State of Florida and/or Nursing Compact
Licensure, Certification, or Registration Preferred:
Nursing Licensure as a Registered Nurse (RN) in good standing with the State of Florida and/or Nursing Compact
Current Certification in Clinical Documentation Improvement (CDIP, CCDS, CCDS-O, CDC, and/or CDEO
Knowledge and Skills Required:
Ability to develop, evaluate and improve workflows including ability to create process documentation
Expertise in computer skills including excel, powerpoint, word, and reporting software
Knowledge of healthcare operations
Knowledge and understanding of medical terminology and medical reporting
Strong background in chronic disease management
Communicate professionally in reporting results
Ability to interact effectively with physicians and other health care professionals
Able to be independent in daily work
Clinical operations knowledge
Able to identify, analyze and effectively solve problems
Ability to prepare reports and presentations, and building/maintaining statistical spreadsheets
Ability to function in a high-paced environment
Utilize and demonstrate excellent critical thinking, problem-solving and deductive reasoning skills
The Nurse CDI (Clinical Documentation Improvement) Specialistwill be responsible for utilizing their clinical/nursing knowledge, and understanding of current CMS coding guidelines, conventions and AHA coding clinics to improve the overall quality and completeness of the patient medical record. Through a multidisciplinary team process, the Nurse CDI Specialist performs pre-visit and retrospective reviews of ambulatory clinical documentation to ensure accurate depiction of the true complexity of the patient. This includes compliant documentation to support the capture or Hierarchical Condition Categories (HCC), ICD-10-CM accuracy and specificity, and medical necessity. They work collaboratively with physicians, advanced practice providers, coders and clinical documentation analysts to communicate opportunities and educate members of the patient care team regarding documentation guidelines, coding requirements and service-line specific requirements. They communicate with coders, compliance specialists and/or clinical documentation analysts regarding documentation clarification and accurate coding, as needed.
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