**On-site position*

Scope of Position

The Clinical Documentation Improvement Specialist (CDIS) 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 CDIS will confer with the appropriate caregiver on the additional documentation that may be required. The Documentation Specialists 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.

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 organizations performance on quality measures and on the Case Mix Index (CMI) which is critical to the financial health of the organization. The CDIS follows The Joint Commission (TJC), Medicare and third party payer documentation guidelines and the official guidelines for assigning ICD- 10-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.

Education:

• Associate's Degree in a health-related field or other Accredited Program Diploma in Nursing required; minimum 2-4 years acute care medical or surgical experience preferred. Intensive Care Unit preferred
• A degree in Health Information Management with credentials of RHIA, RHIT, CCS, CCDS or CDIP with extensive clinical knowledge and a minimum of 2-4 years of inpatient coding experience will be considered in lieu of an RN

Certification and Licensing:

• 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 in lieu of an RN.