Learn how to teach … Date of birth is an important patient identifier. It is important to know which knee and how long ago the procedure was performed. Analyze current areas for improvement. Clinical Documentation Improvement Specialist Resume. Clinical Documentation Improvement Joy presents for a recheck on her simple chronic bronchitis. The following is likely not a surprise to those clinical documentation improvement specialists (CDS) working day in and day out improving physician documentation. Complete and deliver a follow-up report to client, Responsible for providing education and training on clinical documentation improvement principals and methodology (MS-DRG and APR-DRG as appropriate) to the Strategic Sourcing clients, Consulting Practice, and new clients, Educate team and clients on Precyse CDI technology and associated work flows during implementations that combines CDI services and technology, Work in collaboration with Director of Clinical Services Consulting Practice to develop / refine education materials, participate in internal training and client management, Supports Precyse's Compliance Program by demonstrating adherence to all relevant compliance policies and procedures as evidenced by training participation and daily practice; notifying management when there is a compliance concern or incident; demonstrating knowledge of HIPAA Privacy and Security Regulations as evidenced by appropriate handling of patient information; promoting confidentiality and using discretion when handling patient information, Must have high speed internet access and experience with remote access, set-up, and troubleshooting technical issues when working remotely, Weekend travel may be required on occasion, RN or MD Required. You shouldn’t include anything older than 15 years on your resume, or you may run the risk of … and squatting. Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. Headline : Dedicated RN experience with medical-surgical, pediatrics, as well as pre-op surgery. In a previous blog post, More Than Just HCC’s: 6 Best Practices for Outpatient CDI, we discussed the areas that need to be addressed in a comprehensive outpatient clinical documentation improvement (CDI) program.While we recommend going beyond just focusing on Hierarchical Condition Categories (HCC’s), taking a closer look at documentation related to HCC’s is a good place to start. He is to discontinue Nyquil. Cardiovascular: NormalNormal Positive for murmur Provides guidance and strategic direction on CDI issues, Facilitates strong working relationships between Shared Service Center (SSC), Coding, and hospital departments to promote effective clinical documentation improvement through coordination of efforts, Collaborates with HIM and hospital on delinquent queries and month end close processes to ensure accuracy of interim coding on unbilled accounts, Supports hospital initiatives in meeting core measures, patient safety and service excellence goals, Identifies educational opportunities and coordinates division and facility based training programs. GU: BPH, TURP  A lot has been spoken and written about clinical documentation already. This small rural hospital is a 30-bed, fully paper-health dependent facility. Clinical documentation quality is the biggest challenge of medical coding. measures. several case examples (like this one) to expose the most common documentation errors that plague practices. Clinical Documentation • Clinical documentation is any information documented in a patient’s record by any healthcare provider that can impact patient quality, safety, outcomes and mortality • Only documentation from a treating physician (attending, consulting, or surgeon) can be used by coding. Related Terms clinical decision support system (CDSS) A clinical decision support system (CDSS) is an application that analyzes data … No history of a heart Administer 5 units regular insulin per sliding scale. Rapid influenza test performed in the office: negative The latest health care technology can recommend potentially missed clinical indicators or documents lacking required specificity that, if caught early, can lead to higher quality care, exact coding and accurate reimbursement. and rales to bilateral lower lobes. Could be the reason for the pain and swelling. instability, there is swelling and erythema noted, and is warm to touch. He does have a prosthetic joint. are normal on exam. Clinical Documentation Improvement Specialist 12/2013 to Current HCA North Texas Division Dallas, TX. problems have a hereditary link. CDI programs can have multiple positive outcomes, including, but not limited to: Standardizing care across teams; Reducing claim denials and increasing reimbursements; Managing procedure quality and bench-marking; Improving patient throughput and satisfaction; Developing more thorough, accurate procedure notes; Sites that utilize … Cardiovascular: Hypertension Ensure documentation accurately reflects medical necessity, severity of illness, medical care plan, and risk of mortality. were no indications of further complications. Alternative cause for symptoms. The benefits surrounding its success internationally include improved quality and patient safety outcomes and increased reimbursement. This information is important for monitoring and prevention of diabetic retinopathy. Complete and deliver an implementation report to client, Coordinate and lead the team in the performance / management of CDI, CM, and/or UR program follow-up duties, These duties include but not limited to: medical record reviews, staff competency assessments, process flow, review of P&P, interviews, etc. Daily Vitamin, ROS: Oh, And We Have Weather TOO… 3. In the assessment the provider indicates the patient has an enlarged spleen. Date of Exam:  06/22/2010 an electronic health record system for documentation must incorporate all CCBHS-MHP required documentation elements identified in CCBHS-MHP’s Policy 709. Performs chart reviews to ensure appropriate documentation, Fosters effective communication and collaboration with physicians and/or provides training and education related to CDI process. which he relates to seasonal allergies. Self-Paced Clinical Documentation Improvement (CDI) Inpatient-Outpatient Academy . It’s actually very simple. Here’s why: Your coding does more than just get you paid for what your provider did (aka fee-for-service). According to The American Health Information Management Association (AHIMA), CDI is so important in the health care world because it has a direct impact on patient care. Completes and delivers an assessment report to client, Coordinate and lead the consulting team in the performance / management of CDI, CM, and/or UR program implementation duties, These implementation duties include but not limited to: Education of CDI staff, Physician, Ancillary staffs, process flow redesign and implementation, staff mentoring, review of performance metrics, participation in steering committee and other meetings, etc. Prosthesis presents a high risk for infection. Create a Resume in Minutes with Professional Resume Templates, Director Clinical Documentation Improvement Altamonte Springs, Director of the Clinical Documentation Improvement, Clinical Documentation Improvement Resume Samples. Chapter 1. Even though rule out diagnoses are not coded, instruct the provider to document them because it helps support the medical necessity and severity of the patient’s condition. Left Knee: Walks with slight limp. Left knee for routine 4 views Diagnoses must be clinically supported so that denials can be defended. Ability to think critically and analytically, anticipate challenges and trends required, Working knowledge of automated system designs is preferred, Experience in computerized hospital/health information management systems and software applications is required, CDI Outpatient, Case Management and UR experience a plus, Direct experience in working as a CDI Leader or in development of CDI program in the acute care setting and understanding of CDI program infrastructure, workflow and reporting/metrics, Experience leading a large scale consulting project or driving implementation of a client CDIP, Proven success in delivering value to customers through the CDI programming, Strong communication skills including the abilities to present effectively, actively listen and influence/negotiate, Experience in conducting gap analysis, identification of risk and opportunity and development of findings and recommendations, including development of a Road Map, CDIP gap analysis experience preferred but qualified candidates may have comparable experience with other similar initiatives, Strong understanding of both clinical, HIM, Quality and Case Management workflow, Clinical Documentation Improvement Specialist/Professional (CCDS/CDIP) credentials through AHIMA or ACDIS, Direct experience in working as a CDI Specialist or in development of CDI program in the acute care setting and understanding of CDI program infrastructure, workflow and reporting/metrics, Experience in conducting gap analysis, identification of risk and opportunity and development of findings and recommendations, including development of a Road Map; CDIP gap analysis experience preferred but qualified candidates may have comparable experience with other similar initiatives, Individual must be proficient in ICD10 Diagnosis/Procedures Codes, MS-DRG reimbursement and clinical documentation requirements (coder credentials not required), Has facilitated physician education or has experience in working directly and communicating with physicians, Preferred license/credential: RN, NP, PA, MD, RHIA, RHIT, Knowledge of MS-DRG classification and reimbursement structures, Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation, Leadership and organizational skills along with critical, deductive reasoning and problem solving skills, Overall knowledge of the flow of the revenue cycle, Manage change while minimizing interruption at an operational and service level, Preferred: Graduate from a Nursing program, BSN or graduate of Health Information Management RHIT, RHIA, Coordinates and provides ongoing education to care providers regarding documentation requirements for optimal data integrity, data reliability, and clinical coding. Must include the medication and dosage. Develop collaborative relationships with internal resources, consultants, auditors, and physician champions to develop and achieve the established plan, Promotes collaboration and removes obstacles to teamwork across the organization, Work with FH leadership to implement a CDI governance structure responsible for achieving clinical and operational excellence, and expected deliverables in relation to the CDI program at FH Provide leadership support and integrate with other departments/programs such as HIM/Coding, and clinical care departments, Develop a meaningful scorecard, dashboard metrics, peer group comparisons, and service specific data that are actionable. Why put your pediatric CDI program in the hands of a consultant or educator who thinks it is the same as the adult world? Always … Resp. Clinical documentation is the catalyst for coding, billing, and auditing, and is the con-duit for (and provides evidence of) the quality and conti-nuity of patient care. This Clinical Documentation Manual is to be used as a reference guide and is not a definitive single ... and Quality Improvement & Utilization Review Department’s interpretation and determination of documentation standards. Medical Record # 06500. 4. Integument: Skin lesions Appropriately manages resources, Oversees relationship management with payers and network providers, Provide strategic planning and direction for the development and enhancement of CDI program services through the National CDI Center of Excellence. In spite of that, many hospitals still struggle in getting the best out of their doctors when it comes to documentation quality. Treat immediate hyperglycemic condition. Clinical Documentation Improvement—A Physician Perspective: Insider Tips for getting Physician Participation in CDI Programs. Manage department labor tracking and budget in accordance with organizational policies and in conjunction with AVP, Provides leadership and guidance of staffing resources to ensure compliance with department standards; ensuring hours are flexed and over time is avoided as necessary. The Importance Of Clinical Documentation Improvement. Another example is because there are often small differences in the … Tips for Approaching Clinical Documentation Improvement As accurate clinical documentation becomes more important, it's vital to consider multiple approaches to clinical documentation improvement. Claritin Instruct the provider to document all of his concerns. Robin Ingalls-Fitzgerald, CCS, CPC, FCS, CEDC, CEMC. Has had night sweats, which he relates to seasonal allergies to help prepare for the.... Quality reporting ( hello, on their program ’ s for five days hospital clinical! This note bowel sound x4, No joint instability, there is and... 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