Clinical Documentation Improvement Specialist - Bayfront Health

Position Summary :

Bayfront Health is seeking a CDI Specialist who will provide concurrent review of the clinical documentation in the medical record;

review the medical record with a clinical lens to identify any missing or understated diagnoses or procedures.

The CDI Specialist I will be a Hybrid position. Candidates will be required to work on-site 2 days, and remote 3 days out of the week.

Location

701 6th St S.

St Petersburg, Fl 33701

Schedule

Monday - Friday 8am-4 : 30pm

Qualifications : Education / Training

Education / Training

Graduate from an approved school of medicine, or an RN license from outside the state of Florida.

Licensure / Certification

None

Experience

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

Knowledge of age-specific patient needs and the elements of disease processes and related procedures.

Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers

Responsibilities : Essential Functions

Essential Functions

Conducts initial and follow-up concurrent reviews on targeted admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care.

Coordinates with coding / HIM / UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided.

Review medical record concurrently for documentation not yet in the record but supported by clinical indicators. Performs a thorough chart review to identify co-morbidities / complications, and documents these appropriately within the concurrent CDS worksheet.

Determines the appropriate principle diagnosis of the patient.

Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes.

Documents findings in workflow tools, noting all key information used in the tracking process.

Uses relationship building and strong communication skills to develop a rapport with providers to clarify information in the medical record.

Uses appropriate querying tools (templates) to capture needed documentation.

Queries the medical staff when necessary by written and / or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan Provides education to physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or on individually with physicians.

Reviews the progress of the CDI program by interpreting performance, process, and quality ratings reports. Able to identify areas of focus through report analysis.

Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards.

Maintains compliance with all Orlando Health policies and procedures.

Other Related Functions

Performs routine assignments using existing procedures.

Maintains established work production standards.

Develops competence by performing structured work assignments.

Through training, displays conceptual knowledge of theories, practices and procedures related to CDI.

Assumes the responsibility for professional growth and development.

Ability to work independently in a time-oriented environment.

Receives instruction, guidance and direction from others.