[Hiring] Clinical Documentation Improvement Specialist @Children's Health

Role Description

The Inpatient Clinical Documentation Integrity (CDI) Specialist promotes the accuracy, completeness, specificity, and integrity of clinical documentation through concurrent and retrospective medical record reviews. Collaborates with physicians, nursing staff, coding professionals, and interdisciplinary healthcare teams to ensure documentation accurately reflects the patient's clinical condition, severity of illness (SOI), risk of mortality (ROM), and complexity of care. Identifies opportunities for clarification of clinical documentation and facilitates compliant provider queries in accordance with established coding guidelines, regulatory requirements, and organizational policies. Supports accurate diagnosis reporting, DRG assignment, present-on-admission (POA) indicators, clinical validation, and quality reporting. Provides education to physicians and clinical staff while collaborating with coding, quality, and other departments to improve documentation practices, support accurate clinical data reporting, and promote optimal patient care outcomes.

Responsibilities

• Interprets and implements requirements of APR-DRG and Medicare-based reimbursement/payers.
• Completes accurate and timely review to ensure the integrity of the documentation compliance resulting in accurate diagnosis and procedure classification used for reimbursement and quality metrics.
• Recognizes opportunities for documentation improvement using critical thinking skills.
• Uses critical thinking and sound judgment in decision making keeping reimbursement considerations in balance with regulatory compliance.
• Completes initial concurrent reviews of patient records for specified patient populations to evaluate documentation, to assign working DRG, pertinent secondary diagnoses and procedures for accurate APR-DRG assignment, risk of mortality and severity of illness.
• Strategically educates physicians and other clinicians regarding the need for accurate and complete documentation in the health record that includes regulations and compliance guidelines.
• Partners with coding professionals to ensure accuracy of diagnostic and procedure data and completeness of supporting documentation to determine appropriate APR-DRG assignment.
• Queries physicians regarding missing, unclear or conflicting health record documentation.

Qualifications

• At least 4 years Equivalent combination of education and/or experience in Health Information Management, Healthcare Administration, Healthcare Operations, Coding, Nursing, Case Management, or experience as a Physician. Required
• Four-year Bachelor's degree or equivalent experience. Required
• Graduate or professional work or advanced degree; or equivalent experience. Preferred

Requirements

• Licensed medical doctor. Preferred
• Licensed RN, RRT, PT. Preferred
• Registered Health Information Management Technician / Administrator. Preferred
• CCS, CDIP, and or CCDS. Preferred

Benefits

• Employee portion of medical plan premiums are covered after 3 years.
• 4%-10% employee savings plan match based on tenure.
• Paid Parental Leave (up to 12 weeks).
• Caregiver Leave.
• Adoption and surrogacy reimbursement.