[Hiring] Clinical Documentation Integrity Specialist @University Hospitals

Role Description

The Clinical Documentation Integrity Specialist is responsible for utilizing independent clinical judgement in facilitating the integrity, overall quality, accuracy and completeness of provider-based clinical documentation in the medical record. This position is responsible for collaborating with healthcare providers to ensure the documentation in the medical record accurately reflects the patient. The CDI Specialist assesses the clinical documentation through extensive review of the medical record, interacts with multiple members of the healthcare team, educates and assists the clinical areas in effective and compliant documentation.

The CDI Specialist provides guidance with processes in the clinical departments to support accurate, timely and complete documentation in agreement with company policies and procedures.

What You Will Do

• Ensures documentation is accurate and complete by performing timely medical record review and determination of code assignment.
• Direct and timely follow-up with clinical providers to ensure requested clarification is provided.
• Responsible and accountable for expanding CDI and coding knowledge.
• Utilizes critical thinking/problem solving processes.
• Appropriately utilizes and interprets professional association resource materials and regulatory agencies guidelines.
• Identifies query opportunities for record integrity.
• Is proficient in query writing so that the question is easily understood by the physician.
• Escalates non-response to query by physicians immediately according to query escalation policy.
• Collaborates with the coding team.
• Actively engages in educating physicians and other clinical care providers regarding clinical documentation.
• Consistently provides a collaborative relationship with healthcare team providers/members.
• Participates in service line rounding/touch-point routinely.
• Provides ongoing service line directed education to provider teams.
• Applies knowledge of health care workflows to improve the overall accuracy and comprehensiveness of medical record documentation.
• Seeks and provides feedback for improved CDI practice and integrity/quality of medical record documentation.
• Meets established operational and productivity standards.
• Consistently meets productivity, quality, and AHIMA ethical standards.
• Proficient and efficient use of the CDI business platform.

Additional Responsibilities

• Performs review of facility inpatient encounters to ensure hospital case-mix index and severity profiles are accurate.
• Demonstrates proficiency in establishing and reconciling DRG processes compliant with departmental guidelines and CMS regulations.
• Participates in service line rounding/touch-point routinely, based on facility needs.
• Identifies HAC/PSI query opportunity utilizing resources and follows department guidelines for HAC/PSI query processes.
• Demonstrates skills of high efficiency and accuracy to identify and reduce DRG downgrades/denial risks.
• Performs review of facility outpatient encounters identified as potentially missing charges.
• Coordinates with clinical departments to review, correct claims and identify root cause of missing charges.
• Performs analysis of patient clinical and billing data to identify documentation, coding and charging opportunities.
• Develops and maintains project plans and project tracking.
• Auditing and monitoring of defined areas.

Education

• Associate's Degree in health related field (Required) or other Accredited Program: Diploma in Nursing (Required)
• Bachelor's Degree in health related field (Preferred)

Work Experience

• 3+ years clinical and/or ICD-10 coding experience, preferably in a large academic medical center (Required)
• 1+ years Experience using clinical computer systems (Required)

Knowledge, Skills, & Abilities

• Must have thorough, up-to-date clinical skills (i.e. current working knowledge of pathology, pharmacology, surgical procedures, etc.). (Required proficiency)
• Excellent written and verbal communication skills including presentations. (Required proficiency)
• Ability to function independently and as a team player in a fast-paced environment. (Required proficiency)
• Detail-oriented, and relationship building skills. (Required proficiency)
• Demonstrates and has extensive knowledge of disease pathophysiology (Required proficiency)

Licenses and Certifications

• Registered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire)
• Registered Health Information Administration (RHIA) (Required Upon Hire)
• Registered Health Information Technologist (RHIT) (Required Upon Hire)

Physical Demands

• Standing Occasionally
• Walking Occasionally
• Sitting Constantly
• Lifting Rarely up to 20 lbs
• Carrying Rarely up to 20 lbs
• Pushing Rarely up to 20 lbs
• Pulling Rarely up to 20 lbs
• Climbing Rarely up to 20 lbs
• Balancing Rarely
• Stooping Rarely
• Kneeling Rarely
• Crouching Rarely
• Crawling Rarely
• Reaching Rarely
• Handling Occasionally
• Grasping Occasionally
• Feeling Rarely
• Talking Constantly
• Hearing Constantly
• Repetitive Motions Frequently
• Eye/Hand/Foot Coordination Frequently

Travel Requirements

• 10%25