Clinical Documentation Integrity Specialist II; Remote

Clinical Documentation Integrity Specialist II (Remote) ($5K sign on) (25000B99)

A Brief Overview. The Clinical Documentation Integrity Specialist is responsible for utilizing independent clinical judgement in facilitating the integrity, overall quality, accuracy and completeness of provider-based clinical documentation in the medical record. This position is responsible for collaborating with healthcare providers to ensure the documentation in the medical record accurately reflects the patient complexity and resource utilization. The CDI Specialist assesses the clinical documentation through extensive review of the medical record, interacts with multiple members of the healthcare team, educates and assists the clinical areas in effective and compliant documentation.

The CDI Specialist provides guidance with processes in the clinical departments to support accurate, timely and complete documentation in agreement with company policies and procedures.

• Ensure documentation is accurate and complete by performing timely medical record review and determining code assignment applying clinical and/or coding expertise to identify opportunities for improved or clarified documentation that accurately reflects the patient complexity and resource utilization.
• Responsible and accountable for expanding CDI and coding knowledge, keeping up to date on latest research, technology, treatment modalities, etc.
• Utilize critical thinking/problem solving processes.
• Appropriately utilize and interpret professional association resource materials and regulatory agencies guidelines to enhance own skill sets:
  Coding Clinics, AHIMA, CMS guidelines.
• Identify query opportunities for record integrity.
• Be proficient in query writing so that the question is easily understood by the physician.
• Query writing is AHIMA compliant per practice briefs.
• Escalate non-response to query by physicians immediately according to query escalation policy.
• Collaborate with the coding team.
• Demonstrate proficiency in reviewing increasingly complex cases.
• Demonstrate proficiency and efficiency in cross covering for other units, specialties and hospitals as assigned.
• Actively engage physicians and other clinical care providers regarding clinical documentation in a variety of formats, including participation in clinical rounding, service line focused education sessions and one-to-one case specific feedback.
  • Consistently provide a collaborative relationship with healthcare team providers/members.
  • Participate in service line rounding/touch-point routinely.
  • Provide ongoing service line directed education to provider teams.
• Apply knowledge of healthcare workflows to work collaboratively with medical staff and other team members to improve overall accuracy.
  • Seek and provide feedback for improved CDI practice and integrity/quality of medical record documentation.
  • Identify opportunities utilizing resources and follow department guidelines for processes.
  • Comprehend impact of accurate clinical documentation: accurate billing, public reporting, research data, quality metrics, provider scorecards, etc.
• Meet established operational and productivity standards, consistently meeting productivity, quality, and ethical standards, and using the CDI business platform efficiently.
• Serve as a mentor to other Clinical Documentation Specialists, participate in committees.

• Amendment for Inpatient Clinical Documentation Specialist:
  Perform review of facility inpatient encounters to ensure hospital case‑mix index and severity profiles are accurate by performing timely medical record review, determining working DRG assignment and applying clinical expertise to identify opportunities for improved or clarified documentation that accurately reflects the severity of illness and risk of mortality of the patient, direct and timely follow‑up with clinical providers to obtain clarification.
  • Demonstrate proficiency in establishing and reconciling DRG processes compliant with departmental guidelines and CMS regulations.
  • Review increasingly complex (SOI and ROM) cases.
  • Participate in service line rounding/touch‑point routinely, based on facility needs.
  • Identify HAC/PSI query opportunities utilizing resources and follow department guidelines for HAC/PSI query processes.
  • Comprehend impact of accurate clinical documentation beyond establishing a working DRG: accurate billing, public reporting, research data, quality metrics, provider scorecards, accuracy of the UHDDS, Case Mix Index (CMI).
  • Demonstrate high efficiency and accuracy to identify and reduce DRG downgrades/denial risks by ensuring clinical support is beyond dispute for DRG integrity, coding and billing needs.
• Amendment for Outpatient Clinical Documentation Specialist:
  Perform review of facility outpatient encounters identified as potentially missing charges, conduct additional research to help resolve the areas of opportunity and identify the root cause of the issues causing the missed charges.
  • Coordinate with clinical…