Clinical Documentation Integrity Specialist

Role Overview

• This position is responsible for concurrent review of inpatient medical records to identify opportunities for improving the quality of physician documentation.
• This position facilitates modifications to clinical documentation through concurrent interaction with physicians (face-to-face and electronically) and other members of the health care team.
• The goal of this position is to achieve a complete medical record in order to support complete, accurate and timely coding.
• Communicates with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients.
• Utilizes the hospital’s designated clinical documentation system to identify opportunities for physician and hospital outcomes.
• Provides or coordinates education to all internal customers related to compliance, coding, and clinical documentation issues and acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG.
• Responsible for the day-to-day evaluation of documentation by the medical staff and healthcare team in accordance with the hospital’s designated clinical documentation system.
• Gathers and analyzes information pertinent to documentation findings and outcomes.
• Contributes to a positive working environment and performs other duties as assigned or directed to enhance the overall efforts of the organization.
• Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends.
• Identifies patterns, trends variances and opportunities to improve documentation review and process.
• Researches literature and stays abreast of CMS rules and regulations, incorporating changes to daily practice for overall documentation enhancement.
• Assists in the development and reporting of performance measures to the medical staff and other departments and prepares physician specific data information.
• Conferences with key physicians to review outcome information (including physician profile data if relevant) as it relates to documentation clarity, completeness, and correct DRG designation.
• Coaches physicians to improve their documentation so it more accurately reflects intensity of services and severity of illness.
• Documents conference and results.
• Attends various hospital service line meetings, reviewing outcome information, and educating physicians on service line specific improvement opportunities.
• Complies with HIPAA and Code of Conduct policies.
• Assists with special projects as needed.
• Demonstrates competency for individual performance and development in the following areas: Customer Service, Job Skills, Resource Management, Teamwork, and Innovation. Directors shall determine percentage weight distribution for each competency category.
• Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
• Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences.

Requirements

• Must be an RN with a BSN or MSN
• Must have at least 5yrs of recent RN bedside experience in an acute hospital setting
• Must have pediatrics, NICU, Critical care and/or ICU nursing experience to be considered
• Current State of Texas license or temporary/compact license to practice professional nursing
• Five (5) years of inpatient, acute care at the bedside on a nursing unit; ICU experience preferred
• Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
• Possesses a working knowledge of many areas of adult medicine
• Able to assess, evaluate, and teach
• Proficiency in organization and planning
• Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and Internet searching
• Ability and willingness to seek out and accept change
• Demonstrates adaptability, flexibility, and self-motivation, and an ability to work independently
• Knowledge of federal, state and private payer regulations preferred
• Professional, team player, able to communicate well with others
• Strong interpersonal skills and positive attitude.

Benefits

• N/A