[Hiring] Clinical Documentation Integrity Specialist II @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 complexity and resource utilization. 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.

Qualifications

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

Requirements

• 2+ years in CDI Specialist role (Required)
• 3+ years clinical and/or ICD-10 coding experience, preferably in a large academic medical center (Required)
• Experience using clinical computer systems (Required)
• 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)
• Demonstrated ability to use PCs, Microsoft Office suite, and general office equipment (i.e., printers, copy machine, FAX machine, etc.) (Required proficiency)
• Registered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire) or Registered Health Information Administration (RHIA) (Required) or Registered Health Information Technologist (RHIT) (Required) and Certified Clinical Documentation Specialist (CCDS) (Required) or Clinical Documentation Improvement Practitioner (CDIP) (Required)

Additional Responsibilities

• Amendment for Inpatient Clinical Documentation Specialist
  • 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.
• Amendment for Outpatient Clinical Documentation Specialist
  • Performs review of facility outpatient encounters identified as potentially missing charges.
  • Coordinates with clinical departments including Coding, CDM, Finance and others 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.
• Performs other duties as assigned.
• Complies with all policies and standards.

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%