Lead HIM Denial Management and Clinical Documentation Integrity; CDI Specialist - Hybrid
Listed on 2026-01-01
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Healthcare
Healthcare Administration, Healthcare Management
Lead HIM Denial Management and Clinical Documentation Integrity (CDI) Specialist
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Job Summary
Under the supervision of HIM & Professional Coding, Clinical Documentation Integrity and Denial Management Manager, the Lead HIM Denial Management & Clinical Documentation Integrity Specialist is responsible for improving the overall quality and completeness of clinical documentation and prevent the payor denials. Review, analyze, evaluate and compose a comprehensive rebuttal via the appeal process in a timely manner to the DRG denial claims for clinical and coding denials that are received from the insurer/auditor.
Work collaboratively with all members of the Memorial Healthcare team, Clinical Documentation Integrity (CDI), Coding and Revenue Cycle teams to initiate and resolve Clinical DRG and Coding disparities in dispute from the insurer/auditor. Identify patterns/trends in denial claims and recognize opportunities for enhancing optimal DRG reconciliation to prevent risk of denial. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risks of mortality, and complexity of care of the patient.
Exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions or procedures. Educates members of the patient care team regarding documentation guidelines, including attending physicians, consulting physicians, allied health practitioners, nursing, and case management.
Job Summary
Under the supervision of HIM & Professional Coding, Clinical Documentation Integrity and Denial Management Manager, the Lead HIM Denial Management & Clinical Documentation Integrity Specialist is responsible for improving the overall quality and completeness of clinical documentation and prevent the payor denials. Review, analyze, evaluate and compose a comprehensive rebuttal via the appeal process in a timely manner to the DRG denial claims for clinical and coding denials that are received from the insurer/auditor.
Work collaboratively with all members of the Memorial Healthcare team, Clinical Documentation Integrity (CDI), Coding and Revenue Cycle teams to initiate and resolve Clinical DRG and Coding disparities in dispute from the insurer/auditor. Identify patterns/trends in denial claims and recognize opportunities for enhancing optimal DRG reconciliation to prevent risk of denial. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risks of mortality, and complexity of care of the patient.
Exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions or procedures. Educates members of the patient care team regarding documentation guidelines, including attending physicians, consulting physicians, allied health practitioners, nursing, and case management.
Strives for superior performance by consistently providing a product or service to leadership and staff that is recognized as ultimately contributing to the patient and family experience. Recognizes and demonstrates understanding of patient and family centered care.
Primary
Job Responsibilities
- Demonstrates knowledge of and supports hospital mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality statements, corporate compliance plan, customer service standards, and the code of ethical behavior.
- Serves as a role model, coach, resource for the CDI and Inpatient Coding teams for denial prevention opportunities during concurrent record reviews and during the coding process.
- Performs timely and accurate review of denials, appeal determination and submissions, including tracking findings and outcomes in the designated software tool.
- Remain current with regulatory/payer and internal requirements for processing/submitting appeal claims.
- Documents all appeal activity according to department standards to support accurate and timely reporting of denial and appeal status.
- Independently reviews the denial letter criteria received, reviews the medical record and pertinent documentation, laboratory values, imaging, consultant notes and any other documentation within the encounter that is relevant to the stay and uses expertise of pathophysiology, standard medical criteria for establishing diagnoses, presence of clinical support in the medical record documents for documented diagnosis, coding guidelines, and coding clinics…
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