[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. The Clinical Documentation Integrity Specialist performs concurrent chart reviews to validate that the clinical documentation in the medical record appropriately describes the patient’s severity of illness, complexity of care, and risk of mortality to facilitate appropriate coding.

• Analyze medical records to identify incomplete, inconsistent, or inaccurate documentation related to diagnoses, treatments, procedures, severity of illness, and risk of mortality.
• Perform concurrent chart reviews to ensure clinical documentation accurately reflects the patient’s condition, complexity of care, and services rendered to support appropriate coding and reimbursement.
• Facilitate clarification and modification of clinical documentation through concurrent interaction with physicians and members of the healthcare team.
• Periodically analyze coding and documentation data to identify trends, variations, and opportunities for documentation improvement.
• Utilize data analytics, DRG reports, and tracking tools to monitor documentation performance and support performance improvement initiatives.
• Collaborate with physicians, nurses, coders, and other healthcare professionals to clarify documentation and obtain additional information.
• Provide support to coding teams by ensuring documentation supports code assignment and complies with coding guidelines and regulatory requirements.
• Communicate effectively with coding staff and healthcare providers to resolve coding-related issues.
• Conduct training and educational sessions for providers and staff on documentation best practices and coding guidelines.
• Demonstrate knowledge of quality measure initiatives, including Value-Based Purchasing and related regulatory requirements.
• Ensure clinical documentation aligns with organizational policies, coding standards, and payer guidelines.
• Conduct routine audits and reviews of clinical documentation to evaluate quality, accuracy, and compliance.
• Participate in quality improvement initiatives focused on enhancing clinical documentation integrity and coding accuracy.
• Other duties as assigned.
• Use, protect, and disclose patients’ protected health information (PHI) in accordance with HIPAA standards.
• Understand and comply with Information Security and HIPAA policies and procedures at all times.
• Limit viewing of PHI to the absolute minimum necessary to perform assigned duties.

Qualifications

• BSN or PA (Physician's Assistant) or NP (Nurse Practitioner) or Doctorate degree in a medically related field required.
• High school diploma or equivalent required.
• Minimum of 3 years of experience in clinical documentation improvement role required.
• Minimum of 5 years nursing experience in adult acute care in med/surg, critical care, emergency, or PACU required.
• Active RN, MD, DO, NP, or PA license required.
• Certification minimum requirement – CCDS and/or CDIP.
• Coding credential (CCS, CPC, CCS-P) is a plus.
• Current state Registered Nurse license highly preferred.
• Clinic fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems.
• Proficient in CDI tools such as encoder or CDI workflow and reporting tool.
• Proficiency in Microsoft Office Suite.
• Strong interpersonal skills, ability to communicate well at all levels of the organization.
• Strong problem-solving and creative skills with the ability to exercise sound judgment.
• High level of integrity and dependability with a strong sense of urgency and results-oriented.
• Excellent written and verbal communication skills required.

Requirements

• Must possess a smart-phone or electronic device capable of downloading applications for multifactor authentication and security purposes.

Benefits

• Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; sit; perform manual tasks; operate tools and other office equipment.
• Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress.
• Work Environment: The noise level in the work environment is usually minimal.