"Clinical Documentation Improvement Specialist"

Scope of Position

The Clinical Documentation Improvement Specialist (CDIS) is a nurse who is responsible for concurrent review of inpatient medical records to identify opportunities for improving the quality of medical record documentation. Opportunities include identification of cases where diagnoses and procedures are either absent, not stated in appropriate terminology, or are not appropriately recorded. The CDIS will confer with the appropriate professional staff the additional documentation that may be required. The CDIS' goal is to achieve a complete medical record by the time of patient discharge in order to ensure quality documentation that reflect the patients' diagnoses, treatments, and severity of illness, and to facilitate and enhance the coding and DRG assignment process.

Position Summary

This position supports initiatives to improve the quality of documentation by all professional staff within the Ohio State University Health System with specific emphasis on improving documentation used in the coding process. The CDIS follows JCAHO, Medicare and third party payor documentation guidelines and the official guidelines for assigning ICD-9-CM working diagnosis and procedure codes in efforts to continually improve the quality of medical record documentation. The CDIS provides information and reports to the attending physicians and other health care providers in relation to the patient care documentation process, case mix index, and length of stay.

Minimum Education Required

Bachelor's Level Degree Required Qualifications Bachelor's degree in nursing. Minimum of recent 5 years clinical experience. Candidate must possess strong clinical skills and ability to identify areas for improvement in documentation in the medical record. Preferably with experience with medical record coding (ICD-9-CM; ICD-10-CM) and data analysis. Knowledge and experience with medical information computer applications, word processing and electronic spreadsheets. Ability to develop and deliver presentations to various health and financial professionals required.