CLINICAL DOCUMENT CASE MANAGER - CDI SPECIALIST (CLINICAL DOCUMENTATION INTEGRITY)

Monday - Friday 7 am - 3:30 pm, fully remote 

Job Summary
The Clinical Documentation Case Managers are experienced nurses with clinical skills and knowledge in the application of documentation compliance necessary to support patient severity and corresponding organizational reimbursement. There is an expectation of a high level of understanding of the DRG reimbursement process and ICD-10 CM coding guidelines. The position is responsible for the improvement in overall quality, accuracy and completeness of clinical documentation, and assures all documentation describes each patient’s clinical condition as accurately as possible and supports the level of service provided. The incumbent assists to facilitate the required level of detail in clinical documentation by educating and communicating extensively with the Medical Staff, other members of the health care team and Medical Records coding staff and demonstrates improvement in metrics such as CMI, Core Measure compliance, volume of Medical Record coding queries, etc.
Education
Minimum:
Graduate of a Registered Nurse Program
Preferred:
Bachelor Degree in Nursing
Registration/Certification/Licensure
:
Current PA RN license
Preferred: ACDIS credentialed, Certified Coding Specialist, RHIT, or RHIA
Experience
Minimum:
Three years of current medical/surgical/acute care nursing experience or two years of inpatient coding experience.
Preferred:
Documentation Compliance/Coding/DRG experience.
Other Requirements
:
N/A
Status
:
Non-Exempt
Physical Requirements:
The following frequency definitions apply to all Physical Requirements unless otherwise noted:
Occasional:
(0-1/3 of day , 0 - 2.5 hrs/day, 1 - 4 reps/hr)
Frequent:
(1/3 -2/3 of day , 2.5 - 5.5 hrs/day, 5 -24 reps/hr)
Constant
: (> 2/3rd of day , > 5.5 hrs/day, > 24 reps/hr)
xxxxx
NOTE: An asterisk (*) indicates that the item is an essential function.
Non-Material Handling
Standing*
- Remaining on one's feet in an upright position remaining stationary - FREQUENT
Walking*
- Remaining upright on one's feet, and moving about - FREQUENT
Sitting*
- Body remains in a seated position - FREQUENT
Stooping*
- To bend the body downward and forward by bending the spine at the waist - OCCASIONAL
Bending*
- To flex the upper body forward - OCCASIONAL
Twisting*
- To rotate the upper body forward - OCCASIONAL
Climbing*
- To move the body in any direction on equipment or structures that do not include stairs or ladders - N/A
Ladders*
- To ascend and descend ladders - N/A
Stairs*
- To ascend and descend stairs - FREQUENT
Kneeling*
- To move the body downwards and come to rest on both hands and both knees - OCCASIONAL
Squatting*
- To move the body downwards by bending both knees - OCCASIONAL
Crouching*
- To bend the body forward and downward by bending the spine and the legs - OCCASIONAL
Crawling*
- To move the body forward or backwards on hands and knees - N/A
Reaching Horizontal*
- To extend the arms and hands outward, remaining under shoulder height - OCCASIONAL
Reaching Overhead*
- To extend the arms and hands up and out over shoulder height - OCCASIONAL
Grasping*
- Using functional gripping of the hand to handle an object - CONSTANT
Finger Manipulation*
- To manipulate objects with the use of fingers - CONSTANT
Seeing*
- Using visual feedback to accomplish a task or activity - CONSTANT
Hearing*
- Using sound feedback to accomplish a task or activity - CONSTANT
Repetitive Upper Extremity Use*
- Using the arms and/or hands continuously or more than 2/3 of the total time - CONSTANT
Repetitive Lower Extremity Use*
- Using the legs and/or feet continuously or more than 2/3 of the total time - CONSTANT
Material Handling
Pushing*
- To exert a force upon an object in order to move it in a certain direction Pushing refers to moving an object away from theperson
CONSTANT
Up to 20#
Pulling*
- To exert a force upon an object in order to move it in a certain direction Pulling refers to moving an object towards the person
CONSTANT
Up to 20#
Lift*
- Floor to Waist
CONSTANT
Up to 20#
Lift*
- Waist to shoulder
CONSTANT
Up to 20#
Lift*
- Shoulder to overhead
CONSTANT
Up to 20#
Carrying*
- To transport an object or article using the arms or hands (> 10 feet)
CONSTANT
Up to 20#
Environmental Factors
Working alone
- OCCASIONAL
Working in cramped quarters
- FREQUENT
Constant interruptions
- CONSTANT
Working with hands in water
- N/A
Use of power tools
- N/A
Working on ladders/scaffolding
- N/A
Exposure to vibration
- N/A
Exposure to dust
- N/A
Exposure to noise (constant)
- N/A
Exposure to electrical energy (outlets, etc)
- N/A
Exposure to temperature changes (heat, cold, humidity), that require special clothing
- N/A
Exposure to slippery walking surfaces
- N/A
Exposure to solvents, grease, oils
- N/A
Exposure to radiant energy, ie computer terminal (more than 4 hours per shift)
- CONSTANT
Working with bloodborne pathogens
- N/A
Cardiovascular Energy Requirements - Physical Demand
PhysicalDemand
MetLevel
Examples of similar activity intensity
Sedentary toLight
0 - 3.5
Light house cleaning, washing dishes, serving food, food shopping, sitting, standing, computer work.
Medium
3.6 - 6.3
House work (mopping, scrubbing), health club exercising, treadmill work, stretching, yoga, walk/run-playwith children, aerobic class, dancing, carrying bucket/wood, auto body repair, shoveling snow, golf(carrying clubs).
Heavy to VeryHeavy
> 6.4
Calisthenics (push up, pull up, sit up, vigorous effort), carrying groceries upstairs, shoveling coal, bailinghay, fire fighting, sawing by hand, splitting wood.
As relates to this position:
Sedentary to Light - CONSTANT
Medium - N/A
Heavy to Very Heavy - N/A
I. Specific Job Responsibilities