+ GENERAL SUMMARY + The Clinical Documentation Integrity Specialist is responsible for reviewing inpatient medical records to assess and procure accurate and complete documentation of the patients’ diagnosis and procedures. Reports to department leadership. + ESSENTIAL DUTIES AND RESPONSIBILITIES + Reviews Inpatient Clinical Documentation, ensuring that physicians’ and clinicians’ documentation, accurately reflect the patient’s conditions, diagnoses, treatments, and interventions, resulting in accurate reimbursement. + Reviews to ensure the clinical documentation, reflects the patient’s severity of illness, quality of care and resources used. + Provides education to the physicians and ancillary providers regarding accurate, specific and compliant clinical documentation. + Acts as a resource for other departments regarding the importance of clinical documentation integrity, and the need to clinically document following the Federal and State regulations. + Performs all other duties as assigned. + LICENSES AND/OR CERTIFICATIONS + Required Licenses and/or Certifications + + Current Virginia state license as a Registered Nurse or Registered Nurse holding a valid Compact State license required. + Preferred Licenses and/or Certifications + + Certified Documentation Improvement Professional (CDIP) or Certified Clinical Documentation Specialist (CCDS) certification or must be credentialed through AHIMA or ACDIS, within two years of start preferred. + MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS + Required Education and Experience + + Registered Nurse -Professional knowledge of nursing theory and practice at a level normally acquired through the completion of an accredited School of Nursing. + Preferred Education and Experience + + BSN preferred. + + Pediatric and or Clinical Documentation or Utilization Management preferred. + Required Knowledge, Skills and Abilities + + Experience with applying clinical criteria to a medical record review with a Clinical Documentation Integrity focus. + + Knowledge of healthcare payment systems, specifically the MS-DRG, Tricare and APR-DRG reimbursement systems. + + Ability to form positive and collaborative relationships, with Physicians, HIM colleagues, the Physician Advisor and other hospital staff. + + Competent using Microsoft Office Suite, and different Electronic Medical Records. + + Requires Strong organizational, clinical critical thinking and analytical skills. + Preferred Knowledge, Skills and Abilities + + Technical and professional knowledge and skills for clinical operations of the service area, usually acquired through 3 - 5 years’ progressive Clinical/Supervisory experience in a practice setting. + WORKING CONDITIONS + Normal office environment with little exposure to excessive noise, dust, temperature and the like. + PHYSICAL REQUIREMENTS + Click here to view physical requirements. (https://www.chkd.org/uploadedFiles/Documents/Employees/Category%20A%20Jobs.pdf )