Clinical Documentation Integrity Specialist

Job Requisition #: JR59126

End Date: 11/2/2021

Location: Wilmington, Delaware

Position Type: Nursing

Shift: Day Shift, No Rotation

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The Ambulatory Clinical Documentation Integrity Specialist (a CDI Specialist) is responsible for reviewing the overall quality and completeness of provider clinical documentation and risk adjustment code selection utilized to support reimbursement for both the professional and technical components. The aCDI Specialist

assists clinical practices and providers by providing education and support to better understand the relationship of documentation, code assignment, and risk adjustment of the patient population. The aCDI Specialist assists with analysis, trending, and identifying potential issues, root causes, and collaborative plans for improvement.

PRINCIPAL DUTIES AND RESPONSIBILITIES:   

  • Provides education to providers on the appropriate code selection of ICD-10 diagnosis codes.
  • Performs retrospective reviews of patient accounts to identify potential diagnosis opportunities to support risk-adjustment, HCC coding, and educational opportunities.
  • Achieves and maintains current knowledge and understanding of ICD-10-CM and risk adjustment coding through participation in education and training including comprehension of ICD-10-CM Official Guidelines for Coding and Reporting, Coding Clinic, and other regulatory education programs and updates.
  • Demonstrates proficient knowledge of the Coding and Documentation Guidelines and standards of risk adjustment coding and applies this knowledge to the evaluation of medical record documentation.
  • Assists in the development of internal coding and documentation guidelines in accordance with risk adjustment and official coding guidelines.
  • Provides education to the providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record
  • Assists in development and training of ambulatory CDI principles.
  • Supports development of macros, templates, databases and other tools to support accurate documentation.
  • Identifies trends and/or opportunities to improve clinical documentation.  Presents opportunities and potential solutions to the providers and ACO administration.
  • Demonstrates the highest level of confidentiality and conducts self according to AHIMA and AAPC Code of Ethics and ACDIS Code of Conduct.
  •    Performs assigned work safely, adhering to established departmental safety rules and practices;  reports to supervisor in a timely manner any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.
  •    Performs other related duties as required.

DIRECTION/SUPERVISION RECEIVED:

Ambulatory Clinical Documentation Integrity Program Manager

EDUCATION AND EXPERIENCE REQUIREMENTS: 

Required:

Bachelor's Degree in Nursing or related field

Preferred:

Nursing licensure in the state of Delaware

Coding Certification: Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), or Certified Clinical Documentation Improvement Specialist (CCDS)

CCDS-O Certification upon hire or within 1 year of eligibility.

Minimum of 3 years recent experience in varied inpatient or outpatient coding and/or auditing

Clinical Documentation experience highly desirable

EEO Statement: Christiana Care Health System is an equal opportunity employer, firmly committed to prohibiting discrimination, whose staff is reflective of its community, and considers qualified applicants for open positions without regard to race, color, sex, religion, national origin, sexual orientation, genetic information, gender identity or expression, age, veteran status, disability, pregnancy, citizenship status, or any other characteristic protected under applicable federal, state, or local law.


UPDATE: ChristianaCare is committed to prioritizing the health and safety of our patients and caregivers. As we continue to meet the needs of our caregivers and our community through the COVID-19 pandemic, our commitment to health and safety requires that we take new steps to ensure a safe environment for medical care for our patients and a workplace that avoids preventable harm for our caregivers. For this reason, vaccination for COVID-19 is required for all caregivers at ChristianaCare and is considered a safety standard that is job-related and consistent with business necessity for all caregivers.

Why do WE offer careers full of possibilities?

For the Love of Health.

Inclusion & Diversity

At ChristianaCare, we’re committed to treating everyone with dignity and respect. We believe in a safe, inclusive work environment that fosters collaboration between caregivers from all walks of life. We know that each unique viewpoint is vital in delivering high-quality, safe patient care to everyone who walks through our doors. Our policies, benefits, hiring practices, employee resource groups, and corporate citizenship demonstrate our commitment to inclusion and diversity throughout our system.

Why do we embrace inclusion and diversity? For the Love of Health.

Our Values

We serve together in Love and Excellence. Our unique values, Love and Excellence are bold and powerful, and they are the reason why working for ChristianaCare is special. The behaviors associated with our values guide how caregivers interact with everyone they work with and make for an exceptional work experience. We believe that when you lead with Love, Excellence is inevitable.

Benefits

ChristianaCare’s comprehensive total rewards package is one of the most competitive in the region. We are proud to offer excellent benefits that reflect the organization’s commitment to being exceptional today and even better tomorrow.

At ChristianaCare, we provide access to high-quality and affordable benefits designed to meet our caregivers where they are. You can tailor your benefits to meet your needs now and adjust them as your priorities change.

Take advantage of ChristianaCare’s wide-ranging benefit offerings from supporting optimal health through medical, prescription, dental and vision coverage to valuable wellness and work/life programs, which include paid parental leave, coverage for infertility and assisted reproductive technologies, an employer-funded short-term disability program, and more.

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Our Region

A Great Place To Live

Our region offers a diversity of cultures, lifestyles, sports and entertainment events, housing options and educational opportunities. Located between Philadelphia and Washington, D.C., our locations provide easy access to two international airports, employment opportunities in a tri-state area, and proximity to some of the nation's top universities and colleges, as well as beaches in MD, DE and NJ!

Why Delaware? Why Maryland?
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We Serve Together

For the Love of Health

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