Sign-On Bonus: External applicants eligible for up to $2,000.00.

Sign-on bonus eligibility: Open to external applicates who have not been previously employed by CMC in the last rolling 9 months.

This is a TPD (0.2 Status), day shift Clinical Documentation Integrity Specialist position in the Medical Records department.

POSITION SUMMARY

Primary responsibility is to facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, nurses, case managers, coders and other health care team members, the Clinical Documentation Integrity Specialist (CDIS), will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all Medicare inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assisting with education and training related to improving clinical documentation. This position will actively participate in educating appropriate hospital and medical staff about ICD-10.

PRIMARY (ESSENTIAL) DUTIES

Abstract clinical data from the medical record to accurately code and sequence diagnoses and procedures ensuring accuracy of medical record documentation to support maximum reimbursement. Concurrently abstract information from the medical record in accordance with the conventions and rules associated with the International Coding Classification of Diseases and Operation. Abstract information from the medical record in accordance with abstracting guidelines as defined by Meditech, the medical center, HCFA, state, and federal databases. Other duties as assigned by the Director

Within this scope, the CDIS’s essential functions will include but are not limited to:

• Conducts daily reviews of inpatient medical records either in the nursing unit and/or on the computer to identify missing, vague, and/or incomplete diagnoses and procedures
• Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and queries left in the medical record have been answered by the provider
• Utilizes coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation for measuring and reporting physician and hospital outcomes
• Queries physicians on specificity of procedures performed and diagnosis based on accepted coding guidelines, clinical expertise and LifePoint Hospitals policy
• Tracks and trends specific opportunities for improvement through the query process utilizing approved metrics reporting
• Conducts educational sessions with physicians and other health care team members on documentation requirements
• Conducts CDI on-boarding education of all new admitting physicians as part of the hospitals orientation program
• Reviews clinical issues and identified query response concerns with physician advisors
• Participates in data collection to document findings and outcomes to drive quality improvement and improved clinical documentation
• Stays current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic and Official Guidelines for Coding and Reporting related to ICD-10
• Participates in department and facility Quality and Performance initiatives
• Works closely with nursing, case management, quality, risk management, and medical staff credentialing to provide data related to key clinical indicators and operational metrics
• Works in conjunction with the Director of Quality, Medical Staff Credentialing and medical staff leadership to assure effective monitoring and successful completion of identified plans for improvement
• Prepares and presents educational programs to all internal constituents related to clinical documentation issues and coordinates same with clinical staff, physicians, compliance and coding staff
• Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans
• Establishes cooperative working relationship with diverse groups and individuals, medical staff and other health care disciplines and interact with all levels of employees
• Develops and maintains a professional working relationship with medical staff, clinical staff, medical records and business office staff
• Maintains a knowledge base of the characteristics of disease, illness, disabling conditions that directly impact the patient’s state of physical or mental health
• Collaborates, coordinates and consults with members of the healthcare team to facilitate appropriate documentation in the medical record for concurrent chart abstraction and coding
• Understands the legal and ethical issues pertaining to confidentially as well as liability issues for coding activities
• Attends meetings as required and participates on committees and teams as directed

ORGANIZATIONAL RELATIONSHIPS

Interacts in a positive way with: Co-workers, Supervisors, and Hospital Staff. Interacts in a positive and courteous manner with: Physicians, Patients, Families and Guests. Provides assistance and guidance as necessary. Communicates related information when appropriate and/or refers to source of needed information. Uses the appropriate forms to document customer service issues.

DEPARTMENTAL RELATIONSHIP

Communicates in a positive, courteous and helpful way. Follows the appropriate lines of communication in bringing problems or concerns to: Department Head and/or Administration. Communicates and listens in an effective manner. Attends annual mandatory in-services.

Complies with Medical Center policies, and departmental procedures, objectives and improvement activities. Must guard against the unauthorized release of confidential information and must realize that any breach of confidentiality will result in the immediate dismissal. Follows established hospital and/or departmental procedures for dress, personal hygiene, and ID badges, recognizing that proper appearance assists in maintaining a professional image and authority. Acknowledges project requests and follows through in an acceptable time frame.

EDUCATION AND EXPERIENCE

• Education and Training: Licensed Registered Nurse, RHIA, RHIT, CCS, Paramedic, LPN or combination thereof preferred. Prior experience in case management, utilization review, clinical documentation improvement, and/or coding accuracy preferred.
• Experience: Minimum of 4 years’ experience in an acute adult in-patient clinical role for RNs, Paramedics and LPNs with demonstrated critical thinking skills or a minimum of two years’ experience with inpatient coding for coders, process improvement in an acute care facility preferred or equivalent experience. Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Documentation Improvement CDI Practitioner or completion within 36 months. Bachelor’s degree in nursing may be substituted for two years of the required work experience. Knowledge of concurrent coding and documentation improvement, preferred. Experience in development of reference based continuing educational programs using Adult Learning Principles. Must be self-motivated and have the ability to work within the established policies, procedures and practices prescribed by the facility, corporation and the immediate supervisor.
• Affiliations: TBD.

WORKING CONDITIONS

• Works in the following settings: patient care areas, office, and/or classroom environment.
• Sits, walks, and stands intermittently throughout workday.
• 90% of job requires computer data entry and use of software programs.
• Must be able to work independently and as a team member.

On-Call / Weekend Requirements: No.

CMC is located on a 45-acre campus in Missoula, Montana. Nestled in the Rocky Mountains of western Montana, between Glacier and Yellowstone national parks. Our diverse community serves as western Montana’s hub for education and healthcare and offers the perfect blend of four-season outdoor recreation, small town charm and big city amenities.

COVID-19 Update:
Community Medical Center is hiring top talent but we also have a mission of Making Communities Healthier, which means keeping our community safe and to reduce the risk of exposure. We have modified our conditions of employment to include COVID-19 vaccination unless a documented medical or religious exemption is approved.

Employees may meet this requirement by providing proof of having been fully vaccinated against COVID-19 with any of the three COVID-19 vaccines (manufactured by Pfizer, Moderna, or Johnson & Johnson). Employees are considered fully vaccinated if they are at least two weeks past their final dose of an authorized COVID-19 vaccine regimen.

This position is subject to Drug and Alcohol Testing according to MT Law 39-2-205-39-2-211.

Experience

• 4 year(s): Experience in an acute adult in-patient clinical role for RNs, Paramedics and LPNs

• Experience in case management, utilization review, clinical documentation improvement, and/or coding accuracy.
• 2 year(s): Experience with inpatient coding for coders, process improvement in an acute care facility preferred or equivalent experience.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)