Clinical Documentation Integrity Specialist

JOB SUMMARY Under the supervision of HIM # Professional Coding, Clinical Documentation Integrity and Denial Management Manager, the Clinical Documentation Integrity Specialist is responsible for improving the overall quality and completeness of clinical documentation.# 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.# # JOB RELATIONSHIPS Responsible To:############################### HIM # Professional Coding, Clinical Documentation Integrity and Denial Management Manager############################# # Workers Supervised:##################### None.## # Inter-Relationships:####################### All departments, medical staff, patients and families and Internal and external customers. # 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.

Follows guidelines for coding and documentation to ensure physicians and hospital compliance.# Remains current with coding information to ensure accuracy of codes assigned based on documentation.# Guides, supports, and sponsors concurrent clinical coding.# Provides clinical interpretation of physician documentation.# Acts as a liaison between the clinical and coding functions. Completes initial review of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness;

and (b) initiate a review worksheet. Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final DRG assignment upon patient discharge, as necessary. Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed. Comply with industry standards #Guidelines for Achieving a Compliant Query Practice# when composing queries.

Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record. Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge. Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.

Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership. Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues through daily and retrospective documentation reviews and aggregate data analysis. Facilitates change processes required to capture needed documentation, such as forms redesign. Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality.

Reviews and clarifies clinical issues in the health record with the coding professionals that would support…