Role Overview

Review high-acuity patient medical records to identify clinical indicators, documentation gaps, and suspect diagnoses that may impact quality outcomes, risk adjustment, and reimbursement.
Analyze medical records to determine appropriate clinical information and identify opportunities for accurate diagnosis capture and documentation improvement.
Implement and execute clinical data review strategies in alignment with established protocols, program requirements, and organizational standards.
Ensure consistency, accuracy, and adherence to documentation review methodologies within assigned protocols while contributing to the development and implementation of new review processes.
Utilize clinical expertise and coding knowledge to identify opportunities for enhanced documentation accuracy, completeness, and specificity.
Collaborate with risk adjustment, case management, quality, and provider teams to ensure clinical documentation accurately reflects patient conditions, treatment decisions, and diagnoses.
Leverage physician query and communication processes to clarify documentation and improve the quality and completeness of the medical record.
Identify and validate suspect diagnoses using clinical evidence and documentation standards.
Communicate clinical documentation requirements, coding guidelines, and regulatory standards to providers, coders, leadership, and other stakeholders.
Support coding validation efforts by ensuring documentation supports reported diagnoses and conditions.
Assist with provider and staff education regarding documentation improvement, coding compliance, risk adjustment methodologies, and diagnosis capture initiatives.
Maintain comprehensive tracking and management systems for assigned medical record reviews, findings, and outcomes.
Generate reports and communicate findings resulting from chart reviews to leadership and relevant stakeholders.
Monitor and maintain productivity, quality, and accuracy standards as defined by organizational performance metrics.
Ensure all activities comply with HIPAA regulations, CMS guidelines, payer requirements, and organizational policies.
Participate in internal audits, quality assurance activities, and process improvement initiatives.

Requirements

RN or NP/PA and a minimum of 3 years of progressive clinical experience
At least two (2) years of experience in chart review for clinical indications of medical conditions and diagnosis and management options with emphasis on the managed care industry
Strong understanding of ICD-10-CM coding guidelines, clinical documentation improvement principles, and physician query processes.
Experience reviewing provider documentation in outpatient, ambulatory, post-acute, primary care, or value-based care settings preferred.
Experience in working with various electronic health records (EHR) and medical records.

Benefits

Maintain current knowledge of clinical documentation integrity practices, coding regulations, and industry best practices.
Perform other duties, special projects, and responsibilities as assigned.

Post Acute Medical

Open Positions (1)

Other

Clinical Documentation Integrity Review