Job Description

Scope of Position

The Clinical Documentation Improvement Analyst (CDIA) is a nurse or other clinically qualified individual 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 CDIA will confer with the appropriate caregiver on the additional documentation that may be required. The 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 caregivers within the Ohio State University Health System with specific emphasis on improving documentation to support the coding process which ultimately improves the organization's performance on quality measures and on the Case Mix Index (CMI) which is critical to the financial health of the organization. The CDIA follows Joint Commission (JC), Medicare and third party payor documentation guidelines and the official guidelines for assigning ICD-9-CM diagnosis and procedure codes in efforts to continually improve the quality of medical record documentation. The CDIS provides assistance to the attending physician and other health care providers in the patient care documentation process.

Minimum Qualification Required

Education:

Bachelor's degree in Nursing or equivalent experience. Registered Nurse. 2 years of relevant experience required. 2-4 years of relevant experience preferred in acute care medical or surgical experience required. Intensive Care Unit preferred.

A Bachelors degree in Health Information Management with credentials of RHIA, RHIT, CCS, CCDS, or CDIP with clinical knowledge. 2 years of relevant experience required. 2-4 years of relevant experience in inpatient coding/CDI will be considered in lieu of an RN.

Certification and Licensing Required:

• Current Registered Nurse License in the State of practice.

Or

• Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), Certified Coding Specialist (CCS), or Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) could be considered.

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