Clinical Documentation Specialist - ED in Indianapolis, IN at Eskenazi Health

Date Posted: 1/5/2020

Job Snapshot

  • Employee Type:
    Full-Time
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:
    1/5/2020

Job Description



Organization: HHC



Division:Eskenazi Health  



Sub-Division: Hospital  



Req ID:  2836 



Schedule: Full Time 



Shift: Days 

Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 327-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus as well as at 10 Eskenazi Health Center sites located throughout Indianapolis.



JOB SUMMARY:   The goal of the CDI Program is to clarify ambiguous, conflicting or incomplete documentation. The CDI professional works to facilitate the overall quality and completeness of clinical documentation to accurately represent the severity, acuity and risk of mortality profile of the patient being treated. The CDI professional achieves these goals through careful review of all of the information and documentation available concurrently through the patient’s stay. Focused communication with the treating clinical professionals (i.e., queries) will be utilized to obtain improvements in documentation.  

ESSENTIAL JOB FUNCTIONS:  

  • Reviews ED admissions to include inpatient, observation, CDU, trauma and surgical patients seen in the ED and moved on to the OR
  • Performs accurate and timely concurrent clinical documentation reviews in an effort to capture the appropriate physician documentation that will result in accurate ICD-10 coding that best reflects severity of illness and resource utilization
  • Provides ongoing support and consultation to improve the overall quality of medical record documentation; serves as a clinical resource consultant to the HIM coding staff when coders require clinical decision-making and clinical interpretation to determine appropriate code assignment
  • Develops teaching strategies and methodologies to improve program outcomes
  • Assesses all appropriate admissions for POA documentation of the following:  pressure ulcers, vascular-catheter associated infections, indwelling urinary catheter associated infections, surgical site infection (mediastinitis), DVT, pulmonary embolus, risk for falls and others as deemed appropriate
  • Identifies educational needs of medical staff, health team members and HIM coding staff; plans and implements formal/informal introductory and ongoing orientation and training for multidisciplinary staff
  • Provides nursing staff with additional education for nursing documentation to improve quality and accuracy of bedside procedures, critical care time, infusions etc
  • Coordinates/collaborates with relevant facility departments (Case Management, HIM, Revenue Services, etc.) as clinical reviews are performed
  • Acts as a liaison with inpatient Clinical Documentation Specialist and provides report summary  
  • Serves as primary backup for the inpatient Clinical Documentation Specialist
  • Provides ongoing education to ED and admitting physicians regarding appropriate documentation and criteria for admission, observation and level of care to comply with federal and state mandates; uses InterQual, Medicare and other appropriate resources



JOB REQUIREMENTS:  

Indiana licensed Registered Nurse (RN) required. Three (3) years of strong and varied clinical experience in an acute care setting required

  • Recent hospital experience, preferably ED, ICU, CCU or strong Med/Surg preferred
  • Knowledge of CMS Regulations
  • Proficient in PC use, Microsoft applications and working knowledge of hospital department computer systems 

Accredited by The Joint Commission and named one of the nation’s 150 best places to work by Becker’s Hospital Review for four consecutive years and Forbes list of best places to work for women, and Forbes list of America’s best midsize employers’ Eskenazi Health’s programs have received national recognition while also offering new health care opportunities to the local community. As the sponsoring hospital for Indianapolis Emergency Medical Services, the city’s primary EMS provider, Eskenazi Health is also home to the first adult Level I trauma center in Indiana, the only verified adult burn center in Indiana, the first community mental health center in Indiana and the Eskenazi Health Center Primary Care – Center of Excellence in Women’s Health, just to name a few.

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