Clinical Documentation Integrity Specialist

Overview
Founded as a faith-based hospital in 1931 by the Sisters of Charity of the Incarnate Word, Dignity Health – St. Bernardine Medical Center is a 342-bed, acute care, nonprofit hospital located in San Bernardino, California. The hospital offers a full complement of services, including the Inland Empire Heart and Vascular Institute, an award-winning orthopedics program, surgical weight loss, and is an official Neurovascular Stroke Center, as designated by ICEMA. The hospital shares a legacy of humankindness with Dignity Health, one of the nation’s five largest health care systems. Visit https://www.dignityhealth.org/socal/locations/stbernardinemedical for more information.
Responsibilities
Clinical Documentation Improvement (CDIP) - Review clinical documentation to assess the accuracy, specificity, and completeness of physician clinical documentation and to identify if clinical findings suggest the presence of other conditions that are not explicitly documented and not reflecting medical necessity for the requested level of care. Communicate with physicians and other clinical rofessionals to improve documentation completeness, accuracy, and specificity resulting in accurate information for the care team's use in treating patients, communicating patient condition, response to treatment, severity of illness, risk of mortality and treatment complexity, and having the ability to better determine appropriate intensity of service, resource consumption, length of stay and plan for a safe discharge. The need for follow-up communication with physicians will be determined based on existing documentation identified from a review of the clinical record, signs and symptoms of illness, direct patient assessment, diagnostic testing results, treatments prescribed, reactions to treatment, patient behavior or general physical condition, and the determination of whether the documented findings exhibit abnormal characteristics. Based on the RNCM assessment that these exhibit abnormal characteristics and that the existing physician clinical documentation does not correspond, the RNCM will communicate with the treating or consulting physicians, report or refer assessment findings, and obtain written or verbal communication.

• 
  Articulates to physicians the rationale for improving clinical documentation.
• Reviews the clinical record and clarifies with physician(s), the clinical significance of documented signs and symptoms so that inpatient RCP3 Code 2012-03-22 Page 6 of 9 clinical documentation accurately reflects the severity of the patient condition and acuity of care provided.
• Conducts and documents interactions with physicians regarding documentation clarification
• Utilizes the DIGNITY HEALTH approved Clarification Tools
• Documents all verbal and written clarification activity in Optum Ecac
• Educates members of the interdisciplinary care team to promote accurate and complete documentation in the medical record.
• Communicates with the physician when chart review indicates the documentation present does not fulfill the medical necessity criteria, but the patient condition reflects greater needs. Refers cases to the Clinical Documentation Specialist based on assessed need for greater specificity or accuracy in documentation.
• Performs ongoing medical record review using documentation improvement guidelines to evaluate overall quality and completeness of clinical documentation. Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with physician have been recorded in patient's chart.
• Utilizes a variety of collaborative strategies with physicians, mid-level providers, other members of the interdisciplinary team and Health Information Management staff to ensure the severity of illness and level of services provided are accurately reflected in the medical record.
• Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends.
• Confers with hospital coding staff to ensure appropriate DRG assignment and completeness of supporting documentation.
• Additional Tasks as required for position

Qualifications
Experience:

• Three years nursing experience in an acute care hospital required.

Education:

• Graduate of an RN program.

Special Skills:

• Excellent verbal and written skills required.
• Must read, speak and write English fluently.
• Excellent organizational skills required.
• Familiarity with the following: ANA “Nursing: Scope and Standards of practice”, ANA “Code of Ethics for Nurses with Interpretive Statements”, Nurse Practice Act for state of employment Core Measures
• Basic understanding of desk top computers and work Related software.

Licensure:

• Current Registered Nurse (RN) License to practice professional nursing within the state employed
• Relevant certification is preferred (CCM, ABQAURP or ACM)