HCA, Hospital Corporation of America Clinical Documentation Improvement Specialist (CDI) in San Antonio, Texas

General Statement of Duties: The CDI Specialist is responsible for improving the overall integrity of medical records documentation. Facilitates modifications to medical record documentation through appropriate interactions with physicians, nursing staff, other patient caregivers, and medical records coding staff. Advocates for appropriate patient classification relative to the resources consumed and the level of service provided. Supports the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. Follows coding guidelines and all internal hospital policies and procedures to ensure compliance with clinical documentation.

Essential Job Functions:

  1. Conducts initial concurrent review process for all selected admissions to initiate tracking process, documenting findings on DRG worksheets, and identification of other key pathway or quality indicators as appropriate; acts as liaison for documentation efficiencies with Health Information Management, Case Management, Ancillary Departments, Physicians, Nursing and Administration.

  2. Demonstrates knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures; improves the overall quality and completeness of clinical documentation by performing record reviews using clinical documentation guidelines which then supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes.

  3. Interacts and communicates with Physician staff daily as needed – educating them in the process of clarifying documentation in the medical record; conducts follow up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.

  4. Maintains the DRG Worksheet to include abstraction of patient clinical findings relevant to assign an ongoing working DRG, Physician Documentation Request/interactions and visit frequency; in collaboration with the physician and coder, identifies and records principal and secondary diagnosis, principal procedures, and assigns a working DRG.

  5. Identifies needs to clarify documentation in records and initiates communication with physician by utilizing the appropriate “query” tools in order to capture the documentation in the medical record that supports patient’s severity of illness; performs a thorough chart review to identify co morbidities/complications; documents all known MCC’s and CC’s appropriately on the DRG worksheet.

  6. Demonstrates an understanding of the importance of and makes an effort to capture ALL secondary diagnoses (for profiling purposes), including those that do not directly affect the DRG assignment; reviews coder feedback on completed worksheets and individual internal tracking system reports as a means of continuous self evaluation; discusses any issues or concerns with the Director.

Minimum Education and Experience: Registered Nurse (BSN preferred) with current Texas license; three years recent clinical experience in a hospital setting (preferred) with at least 2 years in management capacity (preferred). Utilization Review or coding experience preferred.

Minimum License and Certificates Required: Licensed as a Registered Nurse in the State of Texas

Title: Clinical Documentation Improvement Specialist (CDI)

Location: Texas-San Antonio-Methodist Stone Oak Hospital

Requisition ID: 03132-72093