Clinical Documentation Integrity Specialist II

Role Overview

• Ensures documentation is accurate and complete by performing timely medical record review and determination of code assignment by applying clinical and/or coding expertise to identify opportunities for improved or clarified documentation that accurately reflects the patient complexity and resource utilization.
• Direct and timely follow-up with clinical providers to ensure requested clarification is provided.
• Responsible and accountable for expanding CDI and coding knowledge (keeping up to date on latest research, technology, treatment modalities, etc.)
• Utilizes critical thinking/problem solving processes
• Appropriately utilizes and interprets professional association resource materials and regulatory agencies guidelines to enhance own skill sets: Coding Clinics, AHIMA, CMS guidelines
• Identifies query opportunities for record integrity
• Is proficient in query writing so that the question is easily understood by the physician
• Query writing is AHIMA compliant per practice briefs
• Escalates non-response to query by physicians immediately according to query escalation policy
• Collaborates with the coding team
• Demonstrates proficiency in reviewing increasingly complex cases.
• Demonstrates proficiency and efficiency in cross covering for other units, specialties and hospitals as assigned.
• Actively engages in educating physicians and other clinical care providers regarding clinical documentation in a variety of formats including participation in clinical rounding, service line focused education sessions and one to one case specific feedback.
• 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 in order to work collaboratively with medical staff and other health care team members to improve the overall accuracy and comprehensiveness of medical record documentation, with focus on ensuring accurate reporting of quality outcomes.
• Seeks and provides feedback for improved CDI practice and integrity/quality of medical record documentation.
• Identifies opportunity utilizing resources and follows department guidelines for processes
• Comprehends the impact of accurate clinical documentation in the medical record: accurate billing, public reporting, research data, quality metrics, provider scorecards, etc.
• Meets established operational and productivity standards.
• Consistently meets productivity, quality, and ethical standards.
• Proficient and efficient use of the CDI business platform
• Serves as a mentor to other Clinical Documentation Specialists, participates in committees

Requirements

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

Benefits

• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients.
• Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.