Job Description:

The Clinical Documentation Specialist ensures clinical documentation is accurate, consistent, compliant, and specific through the performance of reviews and initiation of queries to providers to achieve appropriate ICD-10 code and DRG (Diagnosis Related Groups) assignment for each patient.

1. Reviews concurrent documentation of the medical record to realize accurate and complete representation of the Severity of Illness and Risk of Mortality of the patient, resulting in the appropriate ICD-10 code/DRG assignment.

2. Writes compliant queries with all appropriate clinical indicators and evidence from the record summarized in order to request documentation clarification from the physicians, surgeons, and advanced practice providers.

3. Maintains clinical and coding subject matter expertise to accurately identify opportunities to clarify the documentation through the identification of complications and comorbid conditions, procedures, and application of the official coding guidelines for code capture and sequencing. Maintains working knowledge of reimbursement methodologies, regulatory compliance and quality-based programs.

4. Participates in the development and delivery of educational materials in partnership with the CDI education team. Audiences may include Physicians, Surgeons, Residents, and Advanced Practice Providers, interdepartmental teams, CDI specialists, care site or system level leadership. Presentations could be virtual or in-person for either individual or group settings.

5. Precepts/trains new team members to support their knowledge of CDI workflows, clinical and coding expertise, provider engagement, and a compliant query process. Provide ongoing support to peers.

6. Effectively inputs pertinent data, clinical evidence, critical thought processes into the CDI program to ensure accurate and complete data output through reporting of CDI program metrics and other data reporting systems.

7. Works collaboratively with interdepartmental teams within the care sites to align initiatives, education, and action planning to improve the quality of chart documentation.

8. Participates in team projects and ad hoc department projects to support the advancement of the CDI program with national best practice standards and adoption of innovative technologies.

9. Promotes mission, vision, and values of Intermountain Health, and abides by service behavior standards.

10. Performs other duties as assigned.

Education

Required: Associate’s Degree in Nursing, Health Information Management, Healthcare Administration, or related field is required.

Preferred: Bachelor’s Degree in Nursing, Health Information Management, Healthcare Administration, or related field is preferred.

Certification

Required: Active Registered Nurse (RN) license in good standing required or 5 years of acute care CDI experience in substitution for a RN license.

Preferred: Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), or Certified Coding Specialist (CCS) certification is preferred

Experience

Required: Three (3) years of clinical experience in an adult acute care setting or 1 year of experience as a Clinical Documentation Improvement Specialist in an adult acute care setting required. Acute care includes medical/surgical or similar experience integrating knowledge of pathophysiology and acute care and disease management, physical assessment, clinical evaluation and monitoring with best practice treatment modalities for inpatient hospital populations (excluding rehab, psych). Advanced degrees can count for 1 year of experience.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements list must be representative of the knowledge, skills, minimum education, training, licensure, experience, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Knowledge of CMS Medicare, Medicaid, Managed Care and Commercial health plan billing, reimbursement and regulations.

2. Knowledge of quality measures, patient safety indicators, value-based purchasing, risk adjustments, mortality scoring, hospital acquired conditions, CMS 5 star, and external publicly reported quality metrics.

3. Knowledge of how ICD codes, DRGs and SOI/ROM scores are used for reimbursement, public reporting or outcomes, reviewing quality of patient care, financial modeling, strategic planning and marketing.

4. Knowledge of compliance, practice briefs, white papers, and other publications guiding ethical and legal practices of CDI.

5. Knowledge of ICD-10-CM, ICD-10-PCS, Official Coding Guidelines, Coding Clinics, and other guiding references for coding accuracy and compliance.

6. Knowledge of clinical criteria, pathophysiology, evidence-based practice and the ability to stay current on new trends in medical treatment. Ability to articulate concepts to physicians and other health care professionals to educate on clinical documentation requirements.

7. Strong communication skills in order to successfully communicate complex ideas across different groups and educate on areas of needed improvement. Ability to act as a translator between clinical and non-clinical teams. Ability to work collaboratively with diverse groups and to effectively persuade and lead individuals/groups toward consensus.

8. Possess strong critical thinking with the ability to autonomously prioritize work, manage time, and maintain organization to support efficiency and effectiveness.

9. Proficient with multi-platform computer software and applications in order to utilize tools appropriately to track, analyze, calculate, and summarize data and qualitative findings.

10. Regular attendance to perform work on site during regularly scheduled business hours or scheduled shifts is required. Ability to work nights and/or weekends may be required, as determined needed by the department. Ability to travel between care sites, system offices, and/or educational conference locations on occasion.

Physical Requirements:

Location:

Peaks Regional Office

Work City:

Broomfield

Work State:

Colorado

Scheduled Weekly Hours:

40

The hourly range for this position is listed below. Actual hourly rate dependent upon experience.

$35.25 - $54.39

We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.

Learn more about our comprehensive benefits package here ( .

Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

At Intermountain Health, we use the artificial intelligence ("AI") platform, HiredScore to improve your job application experience. HiredScore helps match your skills and experiences to the best jobs for you. While HiredScore assists in reviewing applications, all final decisions are made by Intermountain personnel to ensure fairness. We protect your privacy and follow strict data protection rules. Your information is safe and used only for recruitment. Thank you for considering a career with us and experiencing our AI-enhanced recruitment process.

All positions subject to close without notice.

About the Company:
Intermountain Health