Clinical Documentation Improvement Specialist

Here, it's different. Come join us.

Children's Hospital Colorado has defined and delivered pediatric healthcare excellence for more than 100 years.

Here, the nation's brightest nurses, physicians, scientists, researchers, therapists, and care providers are creating the future of child health. With an optimist's outlook, a trailblazing spirit, and a celebrated history, we're making new strides every day.

We've been Magnet-designated four times by the American Nurses Credentialing Center and are consistently recognized among the best of the best pediatric hospitals with #1 rankings in Colorado and the region by U.S. News & World Report.

As a national leader in pediatric care, we serve children and families from all over the nation. Our System of Care includes four pediatric hospitals, 11 specialty care centers, 1,300+ outreach clinics and more than 10,000 healthcare professionals representing the full spectrum of pediatric care specialties.

Here, we know it takes all of us, every role, to deliver the best possible care to each child and family we treat.

That's why we build our teams toward a foundation of equity in access, advancement, and opportunity. We know teams of individuals with different identities and backgrounds can nurture creativity and innovation. We know we can see, treat, and heal children better when our team reflects the diversity of our patient population. We strive to attract and retain diverse talent because we know a truly inclusive and equitable workforce will help us one day realize our most basic calling: to heal every child who comes through our doors.

A career at Children's Colorado will challenge you, inspire you, and motivate you to make a difference in the life of a child. Here, it's different.

The Clinical Documentation Integrity (CDI) Specialist ensures overall quality and completeness of the clinical documentation. Facilitates clarification of clinical documentation through extensive concurrent interaction with physicians, nursing staff, multidisciplinary care givers and the Health Information Management coding staff to ensure that clinical severity is captured for the level of service rendered, to support accuracy in quality outcomes, and to achieve appropriate reimbursement.

Department Name: Health Information Management
Job Status: Full time, 40 hours per week
Shift:Monday to Friday, 8am to 4:30pm. Remote

• EDUCATION - Associate degree in Nursing.
  EXPERIENCE - Two (2) years of experience as a clinical nurse in an inpatient acute care setting or two (2) years of experience as a Clinical Documentation Integrity Specialist in an inpatient acute care setting.
• EQUIVALENCY - None.
• CERTIFICATION(S) - None.
• LICENSURE -An active Registered Nurse license is required.
  
  

POPULATION SPECIFIC CARE

No direct patient care.

ESSENTIAL FUNCTIONS

An employee in this position may be called upon to do any or all of the following essential functions. These examples do not include all of the functions which the employee may be expected to perform.

Reviews concurrent medical record documentation to assign and monitor DRG assignment and provide a complete representation of the patient's accurate acuity.
Identifies opportunities to clarify the documentation through the identification of complications and comorbidities, procedures, and the application of the official coding guidelines for accurate code capture, specificity, and sequencing.
Composes compliant queries with appropriate clinical evidence from the record to request documentation clarification from providers.
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. Assists with preparation and presentation of clinical documentation monitoring/trending reports for review.
Collaborates with the HIM coding team to support shared understanding and education to promote complete and accurate clinical documentation and correct negative trends.
Participates in the education for physicians, nurse practitioners, case managers, coders, and other members of the interdisciplinary team members to facilitate comprehensive medical record documentation to reflect pertinent clinical evidence to support the diagnoses, treatment, and medical decision making appropriate for each admission.
Facilitates modification to clinical documentation to support the clinical picture, risk of mortality and severity of illness rendered to all inpatients.
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.
Reviews denial cases and drafts appeals with relevant citations from the clinical chart and appropriate clinical references to support argument. Collaboration with CDI and Coding leadership to communicate trends and necessary action plans. Collaboration with physician leaders to strengthen the appeal strategy.

SCOPE AND LEVEL

Guidelines: Developmental, standard, or intermediate level. Guidelines are generally numerous, well established, and directly applicable to the work assignment. Work assignment and desired results are explained by general oral or written instructions.
Complexity: Falls between the entry and full performance/senior level. Duties assigned are generally repetitive and restricted in scope but may be of substantial intricacy. Employee primarily applies standardized practices.
Decision Making: Decisions or recommendations on non-standardized situations are limited to relating organizational policies to specific cases. Brings non routine issues to supervisor. Problems that are not covered by guidelines or that are without precedent are taken up with the supervisor.
Communications: Contacts with team members, clients or the public where explanatory or interpretive information is exchanged, gathered, or presented and some degree of discretion and judgment are required within the parameters of the job function.
Supervision Received: Under normal supervision, within a standardized work situation, the employee performs duties common to the line of work without close supervision or detailed instruction. Work product is subject to continual review.
Physical Requirements

Ability to Perform Essential Functions of the Job

Ability to Perform Essential Functions of the Job

PHYSICAL REQUIREMENTS

Audio-Visual: Color Discrimination - Good
Audio-Visual: Depth Perception - Good
Audio-Visual: Near Vision: Good
Audio-Visual: Far Vision: Good
Audio Visual: Hearing: Good
Motion: Bend: Up to 1/3 of the time
Motion: Reach up to 1/3 of the time
Motion: Carry up to 1/3 of the time
Motion: Pull up to 1/3 of the time
Motion: Push up to 1/3 of the time
Weight Lifted/Force Exerted: Up to 10 lbs. 1/3 or more of the time
General Activity: Sit 2-4hrs per day
General Activity: Stand/Walk 6-8 hrs a day
Use of hands/feet: Precise Motion Function (or fine manipulation)

WORK ENVIRONMENT

Exposure: Exposure to blood/body fluid: Occasional
Exposure to noise/vibration: Occasional
Exposure: Exposure to cold/heat: Occasional
Exposure: Exposure to infectious disease: Occasional
Mental and Emotional Requirements: Handles multiple priorities effectively.
Mental and Emotional Requirements: Independent discretion/decision making.
Mental and Emotional Requirements: Makes decisions under pressure.
Mental and Emotional Requirements: Manages stress appropriately
Mental and Emotional Requirements: Works alone effectively
Mental and Emotional Requirements: Works in close proximity to others and/or in a distracting environment
Mental and Emotional Requirements: Works with other effectively

It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors. We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or any other status protected by law or regulation. Be aware that none of the questions are intended to imply illegal preferences or discrimination based on non-job-related information.

Here, you matter. As a Children's Hospital Colorado team member, you will receive a competitive pay and benefits package designed to take care of your needs that includes base pay, incentives, paid time off, medical/dental/vision insurance, company provided life and disability insurance, paid parental leave, 403b employer match (retirement savings), a robust wellness program, and access to professional development tools, including an education benefit to help you advance your career.

As part of our Total Rewards package, Children's Colorado offers an annual employee bonus program that rewards eligible team members based on organizational performance. If organizational goals are met for the year, the bonus is paid out the following April.

Children's Colorado delivers annual base pay increases to eligible team members based on their performance over the previous year.