[Hiring] Clinical Documentation Integrity Specialist @Med-Metrix

Role Description

The Clinical Documentation Integrity Specialist focuses on the accuracy, completeness and consistency of inpatient clinical documentation to support coding and reporting of high-quality healthcare data. This role involves:

• Performing concurrent chart reviews to validate that clinical documentation appropriately describes the patient’s severity of illness, complexity of care, and risk of mortality.
• Utilizing advanced knowledge of disease processes and medications to analyze documentation and identify gaps.
• Facilitating modifications to documentation through interactions and collaborations with providers, coding, quality, and case management teams.
• Serving as a resource and educator for providers and interdisciplinary care teams.

Qualifications

• Minimum of 3 years of experience in inpatient clinical documentation improvement role required.
• Minimum of 5 years of nursing experience in adult acute care (med/surg, critical care, emergency, or PACU) required.
• Certification minimum requirement – RN, CCDS and/or CDIP.
• Current state Registered Nursing license required.
• Coding credential highly preferred (CCS, CPC, CCS-P).
• Clinic fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems.
• Demonstrated skills in analytical thinking and problem solving.
• Excellent communication and people skills.
• Self-motivated and able to work independently without close supervision.
• Proficient in the use of computers including Microsoft Office (Word, Excel, PowerPoint, etc.), Outlook, and other applications necessary for the CDS role.

Requirements

• Analyzes medical records to identify incomplete or inaccurate documentation related to diagnoses, treatments, and procedures.
• Periodically analyzes coding data to identify documentation variations and determine the cause and appropriateness of such variation; presents findings to management.
• Works closely with healthcare professionals to clarify and obtain additional information needed for accurate documentation.
• Facilitates modification to clinical documentation supporting the clinical picture/level of severity rendered to all patients.
• Collaborates with stakeholders to clarify and improve documentation.
• Provides support to medical coders by ensuring documentation supports assigned codes and compliance with coding guidelines.
• Communicates effectively with coding teams to address coding-related issues.
• Conducts training sessions for healthcare staff on proper documentation practices, coding guidelines, and compliance requirements.
• Utilizes data analytics to identify trends, patterns, and areas for improvement in documentation accuracy and completeness.
• Monitors daily DRG assignment and reports to track performance improvement.
• Demonstrates understanding of current Quality Measure Initiatives including Value Based Purchasing, Pay for Performance, and Readmission criteria.
• Ensures documentation aligns with regulatory requirements, coding standards, and healthcare policies.
• Conducts regular audits to assess the quality of clinical documentation.
• Participates in quality improvement initiatives related to clinical documentation and coding accuracy.
• Uses, protects, and discloses patients’ protected health information (PHI) in accordance with HIPAA standards.
• Limits viewing of PHI to the absolute minimum necessary to perform assigned duties.
• Understands and complies with Information Security and HIPAA policies and procedures at all times.

Company Description

Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, or any other characteristic protected by federal, state or local law.