Clinical Documentation Improvement Specialist

2 days ago

Sarnia, Canada Bluewater Health Full time

**BWH Required Skills**:
The successful applicant will work in compliance with all relevant and applicable legislation and Hospital Policies and Procedures, will practice the Bluewater Health Standards of Performance Excellence and will fulfill their role within the Attendance Support Program parameters. The successful applicant will also possess effective communication and interpersonal skills, will have the ability to work independently and as part of a team, and will have strong attention to detail and accuracy.

Each member of Bluewater Health is called to embrace patient and family-centred care in its fullest form. This includes using techniques and strategies to communicate “I care and I respect you,” providing information in a way patients and families can understand, listening to patients and families to learn what an exemplary healthcare experience means to them, and seeking their perspective throughout their stay and during improvement initiatives.

**Qualifications**:
Bachelor’s Degree preferred
Accredited Health Professional (HIM, RN, RPN, etc) or other Health Care/Clinical Background with quality, utilization, decision support, or clinical experience or equivalent experience/skill required

**Principal Duties**:

- Review charts and complete CDI tool within 24 hours of admission, and again as prescribed or requested.
- Identify the most appropriate principle diagnosis, complications and comorbidities to accurately reflect patient acuity.
- Recognize and facilitate modifications to clinical documentation.
- Confer with coding specialist concurrently to ensure appropriate HIG/ELOS and completeness of supporting documentation, as well as adherence with coding guidelines.
- Ensure accuracy and completeness of clinical information used for measuring and reporting patient, physician and hospital outcomes.
- Attend discharge rounds with inter-professional care team
- Track responses to queries
- Produce reports as requested and produce a monthly summary of response rates and other indicators as developed
- Participate in documentation and quality audits as assigned
- Participation in committees and discussions in regards to ELOS/EDD
- Educate all internal customers on clinical documentation improvement opportunities, coding and funding issues, as well as performance improvement methodologies
- Assist the Coding Team when querying physicians regarding unclear documentation, and facilitate conversations where appropriate; facilitate established Data Quality processes and develop new processes/reports as required
- Assist in monitoring of coding deadlines, submissions and CIHI data reporting, CAC and Codefinder Software Admin, Winrecs Admin

**Statement**:
We thank you in advance for your interest in Bluewater Health, however, only those applicants selected for an interview will be contacted. In accordance with Bluewater Health policy, offers of employment to prospective employees are conditional upon the successful completion and disclosure of a Police Records/Vulnerable Sector Check.

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