[Hiring] Clinical Documentation Integrity Specialist @Quorum Health

Role Description

The Clinical Documentation Integrity Specialist (CDIS) provides clinically based, concurrent and retrospective reviews of all inpatient medical records. CDI Specialists strive to ensure accurate, complete, compliant, concise and consistent documentation that reflects the true clinical scenario of the patient’s encounter. This additionally serves to reflect the true Severity of Illness (SOI), Risk of Mortality (ROM), and Intensity of Services (IOS) rendered to provide quality care and treatment to the patient. The Clinical Documentation Integrity Specialist serves as a liaison between leadership, medical staff, nursing, coding, case management and quality departments. Excellent communication skills and the ability to critically analyze are essential to successful CDI performance.

Key Responsibilities

• Provides clinically based, concurrent and retrospective reviews of all inpatient medical records.
• Ensures documentation accurately reflects quality of care, severity of illness and risk of morality to support correct coding, reimbursement and quality initiatives.
• Proactively contacts physicians or other clinicians as needed to clarify procedures/diagnoses to ensure proper documentation.
• Performs initial case reviews and follow up reviews.
• Submits queries to providers as needed to ensure complete documentation of relevant diagnoses.
• Assigns diagnosis codes following the Official Guidelines for Coding and Reporting and AHA Coding Clinics.
• Promotes a partnership with Coding/HIM team to ensure the accuracy of principal diagnosis, procedures, and completeness of documentation.
• Actively engages and participates in delivery of education to providers through extensive interaction one on one.
• Promotes collaboration and engagement with physicians to support query education.
• Utilizes critical thinking skills and clinical reasoning to identify, clarify, and query accurate representation of documentation.
• Maintains professional competency in documentation and coding practices.
• Communicates effectively with the multidisciplinary team consisting of physicians, nurses, coders, administration and others.
• All tasks must be performed in accordance with the established Quorum CDI daily workflow.
• Communicates in a timely manner with CDI leadership, reporting potential and/or actual problems.
• Consistently demonstrates proficiency in engaging with providers in areas such as education, query follow-up, and face to face interactions.

Qualifications

• Must possess strong organizational, communication and clinical foundation skills.
• Must demonstrate proficiency in EMR software, CDI applications and Microsoft applications.
• Demonstrates ability to multi-task and work efficiently and effectively between software platforms.
• Demonstrates the ability to communicate effectively in a fast-paced environment with multidisciplinary teams.
• Demonstrates proficiency in CDI process after completion of onboarding and orientation/education.
• Ability to work independently, prioritize tasks and demonstrates self-awareness as to when to seek assistance.

Requirements

• Bachelor's degree in a clinical or coding study is preferred.
• 2-5 years acute clinical or coding (IP) experience preferred.
• Clinical Documentation Integrity experience preferred.
• Basic requirements: RN or LVN with current state license, a coding background with sound clinical expertise or a Foreign Medical Graduate.
• CCDS or CDIP preferred/encouraged with proof of certification when applicable.
• Proficiency in Microsoft applications, EMR applications, CDI and coding software.

Benefits

• Competitive salary and benefits package.
• Opportunities for professional development and advancement.
• Supportive work environment with a collaborative team.
• Comprehensive healthcare coverage.
• Retirement savings plan.
• Paid time off and flexible scheduling options.
• Student loan repayment program.