Clinical Documentation Integrity Review

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.