• Facilitates the acquisition and application of clinical, theoretical and financial knowledge and decision-making skills of department staff, physicians, and other health care providers.
• Assesses learning needs, designs, implements and evaluates systems/processes for health care providers to improve patient outcomes.
• Evaluate and integrate appropriate research findings into clinical documentation practices as appropriate.
• Demonstrates continuing expertise in data management and analysis, and enters data into a web-based program. 
• Utilizes advanced knowledge of disease processes, medications, clinical indicators, and all parts of the medical record.
• Makes and accepts data-driven decisions, measures, and metrics. 
• Participates in department and facility Quality and Performance initiatives 
• Works closely with case management, quality management, 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 Improvement, Medical Staff Credentialing and Medical Staff Leadership to ensure effective monitoring and successful completion of identified plans for improvement.
• Analyze documentation, utilize algorithms, encoders, methodologies, and models, identify documentation gaps and opportunities, query, communicate, and achieve documentation outcomes. 

Skills: Clinical Education and Training, Process Improvement, Research Integration, Data Management and Analysis, Clinical Knowledge and Documentation, Decision-Making Skills, Quality and Performance Improvement, Documentation Improvement

• Provides expert-level review of inpatient clinical records within 24-48 hours of admission.
• Conducts follow–up review every 48-72 hours
• Identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the patient condition and acuity of care provided.
• Conducts daily follow-up communication with providers regarding existing clarifications with documentation.
• Effectively articulates the recommendations for improvement along with the rationale.
• Actively communicates with providers at all levels to clarify information and to communicate documentation requirements for appropriate diagnosis based on severity of illness and risk of mortality.
• Provides complete follow-through on all requests for clarification or recommendations for documentation improvement.
• Leads the development and execution of physician education strategies resulting in improved clinical documentation.
• Provides timely feedback to providers regarding clinical documentation opportunities for improvements and successes.
• Ensures effective utilization of the Clinical Documentation Improvement software. 

Skills: Clinical Documentation Review, Follow-up Review, Gap Identification, Communication Skills, Education and Training, Recommendation Articulation, Follow-through, Software Utilization

• Documents and reports all verbal, written, and electronic clarification activity.
• Tracks and reports all verbal, written, and electronic clarification activity.
• Tracks and reports all CDI activities and ensures that CDI impact is reported accurately and appropriately.
• Utilizes only the CHS-approved query forms whether paper or electronic.
• Ensures all queries issued are necessary, compliant, and non-leading.
• Proactively develops a reciprocal relationship with the Coding Professionals to ensure the accuracy of diagnostic and procedural data through the completeness of supporting documentation.
• Collaborates with case managers, nursing staff, ancillary staff and all members of the interdisciplinary care team.
• Adheres to official coding compliance regulations, corporate policies developed to ensure accurate billing, and industry best-practice clinical documentation principles.
• Keeps abreast of regulatory changes related to inpatient coding and documentation and communicates these changes to appropriate corporate and hospital staff.
• Understand key performance indicators.

Skills: Documentation and Reporting, CDI Activity Tracking, Query Management, Collaboration with Coding Professionals, Interdisciplinary Team Collaboration, Coding Compliance, Regulatory Knowledge, Understanding Key Performance Indicators

• Interacts with MD Anderson staff on topics of documentation improvement, coding, case mix, mortality index and expected mortality, length of stay index and expected length of stay, risk adjustment methodologies and models, and other documentation improvement topics. 
• Clearly articulates documentation topics and communicates effectively. 
• Answers the CDI phone line(s) and emails, presents at meetings, and communicates in groups and one-to-one. 
• Prepares guides and resources, and educates members of the patient care team. 
• Communicates with physicians, APPs, case managers, coders and others to facilitate comprehensive medical record documentation. 
• Be an effective change agent, resource, educator, and communicator.
• Advanced use of algorithms and models (i.e. mortality index, length of stay index, etc). 
• Identifies and records the most appropriate working principal diagnosis in compliance with coding guidelines and regulatory compliance. 
• Identifies opportunities in concurrent and retrospective documentation and addresses documentation opportunities. 
• Reviews and Queries Validates documentation reflects the medical complexity and facilitates proper coding which provides an accurate accounting and reporting of the clinical severity and complexity of care including the principle diagnosis, present on admission comorbidities, present on admission (POA), CCs and MCCs, DRG and DRG weight, severity of illness, risk of mortality, expected mortality, expected length of stay, risk adjustment, and other factors and metrics derived from documentation and coding. 

Skills: Clinical Documentation Improvement, Communication Skills, Educational Resource Development, Change Management, Advanced Use of Algorithms and Models, Coding and Compliance, Clinical Data Analysis, Interdisciplinary Collaboration

• Conducts timely initial and follow-up reviews, documents review details, sends queries, and proactively and routinely takes action through conclusion to ensure documentation clarified with the treating provider(s) has been recorded in the medical record. 
• Meets or exceeds productivity, quality, timeliness, and outcomes standards.
• Change Readiness and Advance Professional Competence Exemplify CDI expertise and innovation. 
• Demonstrate, and ongoing investment in and growth of, CDI knowledge, industry changes, innovations, and opportunities. 
• Keeps pace with changes, dynamic factors, and advances. 
• Apply expertise and innovation to support the institution's goals and interests. 
• Continuous improvement, demonstrates change readiness, change acceptance, change management, and PI/QI methods and behaviors. 
• Adapts and maximizes CDI practices, metrics, and outcomes.
• Knows and applies coding rules, guidelines, and accepted standards of coding and clinical documentation improvement practice. 
• Keeps current, learns and applies coding updates and changes. 

Skills: Clinical Documentation Improvement, Productivity and Quality Standards, Change Management and Readiness, Continuous Improvement, Coding Knowledge, Adaptability and Innovation, Professional Growth and Development, Documentation and Query Management

• A good working knowledge of  Nursing and/or healthcare or other related field.
• Clinical experience in an acute care setting or equivalent experience in Health Information Management/Coding.
• Understanding of MS-DRG and APR-DRG assignments and fundamentals of establishing a DRG.
• Working experience or a good knowledge of ICD-10
• Clinical Documentation Specialist experience in an acute care setting.
• Possesses strong clinical skills and knowledge.
• Proficient with the use of various computer applications.
• Ability to quickly learn new systems.
• Excellent verbal and written communication skills.
• Strong interpersonal skills particularly in working with physicians, nurses and coding auditors.

Qualifications: BS in Health Information Management with 3 years of Experience

• Excellent interpersonal skills including excellent verbal and written communication skills
• Proficient in and demonstrates excellent physician relations.
• Able to organize and present information clearly and concisely
• Excellent computer and keyboarding skills
• The ability to use multiple software programs simultaneously
• Have a high degree of prioritization skills.
• Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist.
• Be dependable, self-motivated, and pleasant.
• Utilize and demonstrate excellent critical thinking, problem-solving and deductive reasoning skills.
• Knowledge of pathophysiology, disease processes and treatments.

Qualifications: BS in Medical Informatics with 2 years of Experience

• Must have an RN, Coder, or Healthcare Professional.
• Recent working experience as an inpatient coder.
• Certificate from an accredited coding school.
• Have NY State Licensed RN or PA, as well as CCS, HRIT RHIA or CCDS
• The ability to work as part of a team.
• Must demonstrate data quality and integrity skills.
• Strong working knowledge of word processing software, spreadsheet software and reporting software. 
• Experience working with encoder software, clinical documentation improvement software and electronic medical records
• Strong ability to organize/triage work and manage multiple priorities at once.
• Tthe ability to educate members of the healthcare team about clinical documentation. 
• Recent experience in adult medical/surgical acute care, utilization review, case management, or clinical documentation improvement.

Qualifications: BS in Nursing with 5 years of Experience

• Acute hospital nursing working experience (e.g. medical/surgical unit, intensive care). 
• Experience in Utilization Management/Case Management, Critical Care, patient outcomes/quality management and/or inpatient coding
• ICU/Critical Care working experience
• Prior experience in clinical documentation improvement, ICD coding and MS-DRGs
• Prior working experience in educating physicians/providers
• Previous experience working in a clinical documentation improvement department or as a consultant
• Proven working experience in auditing 
• A comprehensive knowledge of medical terminology, disease processes and clinical competency.
• Excellent communication (verbal and written), interpersonal skills
• Strong collaboration and relationship-building skills.
• Strong critical thinking skills and the ability to integrate knowledge

Qualifications: BS in Health Administration with 6 years of Experience

• A current and valid New Jersey Registered Nurse license 
• Have an MSN (Master of Science in Nursing) or APN (Advanced Practice Nurse)
• Medical/surgical or critical care nursing experience
• Excellent prioritization and organizational skills
• The ability to communicate effectively at a high level
• A certified Clinical Documentation Specialist (CCDS) or certification within 2 years of eligibility
• Previous Clinical Documentation Integrity working experience
• Must possess excellent communication, writing and interpersonal skills
• Possess excellent organizational as well as analytical skills
• Ability to interact well with physicians and other members of allied health care team, including HIM coders

Qualifications: BS in Public Health with 4 years of Experience