Ability to establish cooperative working relationship with diverse groups and individuals

							               RN Clinical Documentation Improvement
Position Purpose:
Under the limited supervision of the Department Manager, conducts reviews of inpatient
medical records either at the bedside and/or on the computer to identify missing, vague,
and/or incomplete diagnoses; communications the need for additional documentation to
the appropriate medical staff, coding and their co-workers; ensures the additional
documentation is completed in a timely manner; works collaboratively other departments
including coding, compliance, the medical staff, utilization review/case management,
health information services (HIS) and any other applicable departments to improve the
quality of physician documentation; supports initiatives to improve the quality of
documentation by all caregivers.

Requirements (Education, Work Experience, Licensure, Registry and/or
Certifications):
       Graduation from an accredited school of nursing and five years related nursing experience
       Bachelor’s degree in nursing may be substituted for two years of the required work experience
       Current licensure as a registered nurse in state of practice
       Excellent critical thinking skills with the ability to quickly make decisive decisions from limited
        written and/or oral information; excellent reading comprehension
       Extensive knowledge of disease processes and clinical outcomes
       Excellent communication skills with ability to express oneself in writing and orally; and comfort
        speaking in small groups
       Must have strong computer skills and the ability to type on a keyboard. Prefer experience with
        Microsoft Office products including Excel
       Ability to establish cooperative working relationship with diverse groups and individuals, medical
        staff and other health care disciplines and interact with all levels of employees
       Employee should possess: the ability to work with minimum supervision; organizational and
        administrative skills; function in a stressful environment; encourage and assist with team building;
        and the ability to maintain the confidentiality of sensitive information, both patient and employee

Physical Requirements:
Include as appropriate per your organizational policy

JOB REQUIREMENTS:

Job Responsibility: Weight 30%
Issues queries/requests for additional documentation as appropriate based on
medical evidence in the chart of an incomplete, missing, or vague diagnosis and/or the presence of the
condition on admission

Success Criteria:
    Communicates effectively with the medical team through written and/or verbal means to elicit
        cooperation with requests for additional documentation
    Accurately communicates the issuance of a query to the medical team, other members of the CDI
        team, and coding team using the applicable database and updates the status of the query daily
        including revising the MS-DRG as necessary to reflect new documentation
    Accurately issues queries as evidenced by an average agreement rate as follows from the medical
        staff when queries are placed for a reimbursement, HAC, and/or SOI/ROM issue


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              o Mentor = >85% agreement
              o Consistent = 60% -85% agreement
              o Inconsistent = <60% agreement
         Appropriately distinguishes between queries and educational queries, issuing educational queries
          when the additional documentation will not impact reimbursement or the mortality index of
          deceased patients

Job Responsibility: Weight 25%
Provides education regarding federal regulations and coding guidelines to the medical staff to assist them
with accurately reflecting the severity of illness and risk of mortality of a patient through use of diagnoses
that can be captured by ICD-9 codes.

Success Criteria:
The same documentation errors will not be made by the same provider multiple times. Education will be
tracked by interdepartmental rounding log. Staff are expected to round on internal customers (the medical
staff and/or nurse managers or service line administrators) at least weekly and/or attend the relevant
discharge planning meeting and/or staff meetings on assigned unit(s) at least weekly.
         8 or more internal customer contacts per month = 5
         6-7 internal customer contacts per month = 4
         4-3 internal customer contacts per month = 3
         2-3 internal customer contacts per month = 2
         < 2 internal customer contacts per month = 1
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Job Responsibility: Weight 25%
Serves as a resource to their CDI peers, medical staff, coding staff and all other hospital employees regarding
the impact of inpatient physician documentation on the financial and quality standing of the facility.

Success Criteria:
    Accurately review assigned medical records per protocol/policy as evidenced by an average
        agreement rate with coding as follows with your final working DRG by coding/CDI
        manager/discharge CDI nurse i.e., the disagreement is not due to a procedure, change in
        documentation after review, etc.
             o Mentor = >90% coder agreement
             o Consistent = 75% -90% coder agreement rate
             o Inconsistent = >75% coder agreement rate
    Accurately communicates review findings to other member of CDI team and coding staff using
        applicable databases i.e., assigns follow up prompts appropriately, consistently documents work MS-
        DRG, principal diagnosis, CC and/or MCC with its location in the medical record, GLOS, and SOI/ROM
    Understands and can articulate MS-DRG reimbursement methodology i.e., assist with establishment
        of a principal diagnosis, assist with identification of CC/MCC, explain the importance of the GLOS, etc.
        as evidenced in their daily review practices, interaction with coding staff and interaction with
        medical staff during rounds and/or via e-mail.
    Works cooperatively with quality staff and coding staff to reach hospital goals for the mortality index
    Assists in the development, revision and/or implementation of educational tools



Job Responsibility: Weight 15%
Communicate effectively with the medical team to ensure timely response/completion to open queries.

Success Criteria:
    Communicates effectively with the medical team through written and/or verbal means to elicit
        cooperation with requests for additional documentation

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       Accurately communicates the issuance of a query to the medical team, other members of the CDI
        team, and coding team using the applicable database and updates the status of the query daily
        including revising the MS-DRG as necessary to reflect new documentation.
       Tracks query responses daily
            o Mentor = >90% closure rate
            o Consistent = 75% - 90% closure rate
            o Inconsistent = <75% closure rate

Job Responsibility: Weight 5%
Demonstrates accountability for personal and professional competencies; maintains a professional
appearance and demeanor.

Success Criteria:
   • Stays current with annual updates to the Inpatient Prospective Payment System (IPPS)
   • Responsible for maintaining clinical knowledge and skills in area of expertise
   • Works closely with coding staff to identify changes in coding directives and assists with the
        dissemination of that information
   • Participates in departmental and divisional staff meetings and educational opportunities
   • Participates in professional organizations pertinent to area of specialty
    Participates in workshops and seminars to enhance financial, coding and clinical skills as it pertains
        to the position




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