Job Description

A Brief Overview:
The Clinical Documentation Integrity Specialist uses clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of inpatient and/or outpatient medical records to evaluate the clinical documentation of clinical services by identifying opportunities for improving the quality of medical record documentation.  Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate communication, severity of illness, expected risk of mortality, and complexity of care of the patient.

The successful Clinical Documentation Integrity Specialist will be adept in clinical experience and knowledge, understanding documentation and coding guidelines, recognizing gaps and issues, as well as the impact of documentation and coding on the patients, the providers, the hospital and related outcomes.

What you will do:
The functions performed by employees in this job family will vary by level or the area(s) to which assigned, but may include (and not be limited to) the following:

Documentation and Coding Analysis:
•       Reviews clinical documentation to facilitate the accurate representation of the severity of illness, expected risk of mortality, and complexity of care by improving the quality of the physician’s clinical documentation.
•       Initiates medical record review within 24 to 48 hours of admission.  Monitors, systematically, the targeted medical records within at least 48 hours unless otherwise indicated) to determine compliance to established documentation standards. Conducts follow-up reviews to ensure points of clarification have been addressed/documented in the medical record.
•       Utilizes Hospital coding code set, policies and procedures, Federal and State coding reimbursement guidelines, and application of the Coding Clinic Guidelines to assign working DRG, reviewing patient records throughout hospitalization that have been identified as focus DRG by regulatory agencies or the facility to ensure the codes are reported at the highest specificity.
•       Partners with the Inpatient coding staff to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, risk of mortality and quality outcomes.
•       Advises and counsels clinical providers in assigned areas in clinical documentation and coding concepts, query procedures and processes.
•       Responsible for units and/or service lines assigned by manager.
•       Maintains liaison with department or service line clinical providers in documentation Integrity strategies, opportunities and specific clarification requests.
•       Suggests improvements to enhance documentation Integrity or clinical provider documentation process.

Documentation Integrity Strategies and Provider Partnership:
•       Contributes to provider engagement, relationship establishment and maintenance related to CDI and documentation Integrity efforts, with all providers.
•       Addresses abnormal ancillary test findings when they occur and query physicians on a current basis to include face-to-face interactions regarding the impact on patient care and DRG assignment.
•       Initiates physician interaction when ambiguous, missing or conflicting information is in the medical record, through the physician query process and/or participation in rounding with the physicians by requesting additional documentation for correct coding and compliance necessary for accurate reflection of CMI, LOS, and optimal resource utilization.
•       Assists CDI service line teams and leadership in the ongoing evaluation of clinical documentation and potential improvement initiatives.

Documentation Performance, Reporting and Enhancements:
•       Performs ongoing documentation analysis for assigned units and/or service lines and submits documentation clarifications or queries to mitigate gaps or inconsistency in documentation, thus ensuring the accuracy of code capture and resulting outcomes.
•       Assists other peers and leadership understanding variance and other documentation and CDI related barriers.
•       Develops or recommends improvements/enhancements to documentation tools, provider engagement and/or processes related to documentation and related outcomes, as needed.
•       Assists in reconciling query and non-query impact within the CDI data entry systems.
•       Project management regarding clinical documentation initiatives and analysis of potential scope expansion or opportunity identification and resolution
•       Performs other related and incidental duties as needed or required.

Knowledge:
•       Requires basic clinical, coding and/or CDI knowledge and understanding of the theories, concepts, principles and practices of medical record documentation and/or data analysis.
•       Learns to apply professional principles, theories, and concepts through work assignments.

Education Qualifications:
•       Bachelor’s degree in Nursing, Medicine, Health Information Management or similarly related field of study.  

Experience Qualifications:
•       ICU/ED and Academic Medical Center experience preferred. 
•       Case management, utilization review and/or direct provider interaction experience, preferred. 

Required Knowledge, Skills and Abilities:

Computer Skills:
•       Beginning to intermediate MS Office Suite applications.
•       Some exposure to an encoder and/or electronic health record systems.
 

Analysis & Problem Solving:
•       Demonstrates ability to analyze problems and issues and understand the regulatory and reimbursement impact of those decisions.
•       Demonstrates critical thinking skills, able to assess, evaluate, and teach.
•       Demonstrates organization and analytical thinking skills.
•       Demonstrates knowledge of and application of AHIMA and ACDIS Ethical Standards.
•       Knowledge of, but not limited to, current CMS coding guidelines and methodologies, MS-DRGs, APR-DRGs, HCCs; ICD-10-CM/PCS and AMA CPT coding guidelines and conventions.
•       Demonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice.
•       Ability and willingness to seek out and accept change.
•       Demonstrates judgment and independent decision making.
•       Ability to work independently in performing duties with minimal supervision with a high degree of self-motivation.
•       Knowledge of the principles and practices of financial analysis and cost accounting.
•       Knowledge of local, state, and federal regulatory requirements related to the functional area.
•       Ability to analyze and develop solutions to problems.
•       Ability to analyze information, reach valid conclusions, and make sound recommendations.
•       Ability to apply judgment and make informed decisions.
•       Ability to communicate complex concepts in simple form to non-CDI or Revenue Cycle experts to understand the appropriate use and limits of the information provided.
•       Ability to manage, organize, prioritize, multi-task, adapt to priorities, and meet deadlines.
•       Ability to learn new solutions, functionality, and technology.
•       Ability to effectively and autonomously manage projects involving multidisciplinary teams and work flows.

Reporting & Data Management:
•       Ability to provide concise reports of activities and results.
•       Ability to work with clinical manager and physicians to make clinical documentation improvements e.g. change clinical documentation processes.
•       Ability to successfully navigate multiple projects and responsibilities
•       Ability to track activities and communications across multiple physician services and forums. Able to work on multiple tasks; independent in prioritizing work.
•       Ability to create, deliver and manage educational content related to clinical documentation Integrity
•       Proficient with Microsoft Applications including word processing, spreadsheets, and presentation software
•       Knowledge of analytical research procedures and methods.
•       Ability to assess reporting systems and develop process/procedural improvements.
•       Ability to capture and understand data from available sources and turn it into useful information for decision-making.
•       Ability to assess data and reporting tools or make recommendations regarding their improvement or enhancement.
•       Ability to perform tests, data auditing, and implementation of CDI and Coding software or documentation processes.
 

Customer Support / Interactions with Others:
•       Ability to develop and maintain supportive, collaborative relationships with Physicians and other clinical professionals.
•       Demonstrates interpersonal, verbal and written communication skills in dealing with inter and intradepartmental activities.
•       Collaborates with others as a "team player", including interdepartmental team work; contributes to effective team action. Able to work with a variety of individuals and groups within the organization.
•       Mastery in verbal and written English communication.
•       Ability to communicate effectively, orally and in writing, including summarizing data and presenting results both one-on-one and in group settings.
•       Ability to guide and educate staff on procedures and processes.
•       Ability to support the education and training of end-users.
•       Ability to provide advice and counsel clients/customers on a broad range of CDI, coding, outcomes and documentation matters regarding effectiveness, compliance and efficiency.

Licenses and Certifications
•       RN  - Registered Nurse - State Licensure And/Or Compact State Licensure preferred