Senior Clinical Documentation Improvement Specialist

Patient SafetyFull TimeDay 8 Hour Shifts (8am - 4 : 30pm)40Req# 42230

JOB DESCRIPTION SUMMARY :

Under the supervision of the Director of Quality and Patient Safety (GBMC), the Clinical Documentation Improvement Specialist is responsible for supporting the reduction of hospital-acquired conditions (MHACs and PSI-90s). Through review of clinical quality outcomes, supports and coaches providers in accurate documentation. Conducts review of assigned hospital acquired conditions and collaborates with the quality, coding, and clinical teams to improve outcomes. Conducts education and training on effective, compliant clinical documentation. Assesses documentation gaps and formulates appropriate CDI educational tools to support measurable improvement. Identifies quality of care trends and issues and reports them to the Director of Quality and Patient Safety (GBMC).

Education

Bachelor’s Degree preferred

Experience

At least three years’ experience as a Clinical Documentation Specialist and / or educator

Knowledge, Skills and Abilities

• Must demonstrate understanding of the APR-DRG system, impact on case mix index as well as ICD-10 coding systems and how guidelines relate to clinical documentation improvement.
• Demonstrates competency in teaching / learning process.
• Demonstrates extensive clinical knowledge and understanding of anatomy, physiology, and pathophysiology.
• Must have a thorough understanding of clinical documentation principles, guidelines, and regulations.
• Solid understanding of Maryland Pay for Performance Programs including criteria for documentation.
• Ability to analyze complex clinical scenarios and apply critical thinking
• Must be able to communicate effectively with peers, physicians, nursing, and other staff.
• Demonstrated interpersonal skills that promote collaboration and teamwork.
• Must demonstrate abilities to train and deliver education programs.
• Must possess strong verbal and written communication skills and be able to produce training presentations and materials.
• Proficient in Epic, 3M 360, and Microsoft Office
• Experience in problem-solving and process improvement

Licensures, Certifications

Physical Requirements

Working Conditions

GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.