Clinical Documentation Integrity Specialist- Remote

Med-Metrix

Parsippany-Troy Hills, NJ(remote)

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JOB DETAILS

JOB TYPE

Full-time

SKILLS

Acute Care, Analysis Skills, Blood-Borne Pathogens, Case Management, Certified Coding Specialist (CCS), Clinical Data, Clinical Study Publications, Clinical Support, Coding Standards, Critical Care, Data Analysis, Diagnosis-Related Group (DRG), Disease, Documentation, Emergency Care, Genetics, HIPAA (Health Insurance Portability and Accountability Act), Healthcare, Healthcare Providers, Healthcare Quality, Hospital, ICD-10, Infectious Diseases, Information/Data Security (InfoSec), Medical Coding, Medical Office Administration, Medical Records, Medications, Microsoft Excel, Microsoft Office, Microsoft Outlook, Microsoft PowerPoint, Microsoft Word, Military, Nursing, Office Equipment, Patient Care, Performance Analysis, Performance Management, Peripheral Hardware, Postanesthesia, Purchasing/Procurement, Quality Assurance, Quality Management, Quality Metrics, Registered Nurse (RN), Regulatory Compliance, Regulatory Requirements, Reimbursement Guidelines, Risk, Safety Standards, Security Compliance, State Laws and Regulations, Support Documentation, Trend Analysis

LOCATION

Parsippany-Troy Hills, NJ

POSTED

Today

Job PurposeThe Clinical Documentation Integrity Specialist focuses on the accuracy, completeness and consistency of inpatient clinical documentation to support coding and reporting of high-quality healthcare data. The Clinical Documentation Integrity Specialist performs concurrent chart reviews to validate that the clinical documentation in the medical record appropriately describes the patient’s severity of illness, complexity of care, and risk of mortality to facilitate appropriate coding. The Clinical Documentation Integrity Specialist utilizes advanced knowledge of disease processes, medications, and has critical thinking to analyze current documentation to identify gaps in clinical documentation. The Clinical Documentation Integrity Specialist facilitates appropriate modifications to documentation through extensive interactions and collaborations with providers, coding, quality, and case management teams. This team member serves as an effective change agent as a resource and educator for providers and interdisciplinary care teams. Duties and ResponsibilitiesAnalyzes medical records to identify incomplete or inaccurate documentation related to diagnoses, treatments, and proceduresPeriodically analyzes coding data to identify documentation variations and determine the cause and appropriateness of such variation; presents such findings to the managementPerforms concurrent chart reviews to validate that the clinical documentation in the medical record appropriately describes the patient’s severity of illness, complexity of care, and risk of mortality to facilitate appropriate codingWorks closely with physicians, nurses, and other healthcare professionals to clarify and obtain additional information needed for accurate documentationFacilitates modification to clinical documentation supporting the clinical picture/level of severity rendered to all patients at the Hospital for DRG based payers through concurrent interactions with physicians and other members of the health care teamCollaborates with healthcare providers, physicians, nurses, and other stakeholders to clarify and improve documentationProvides support to medical coders by ensuring documentation supports the assigned codes and compliance with coding guidelinesCommunicates effectively with coding teams to address coding-related issues and promote accurate code assignmentConducts training sessions for healthcare staff on proper documentation practices, coding guidelines, and compliance requirements, as requested by CDI managerUtilizes data analytics to identify trends, patterns, and areas for improvement in documentation accuracy and completenessMonitors daily DRG assignment, DRG reports and tracking areas for performance improvement to appropriately reflect optimal severity at admission and through the stayDemonstrates an understanding of current Quality Measure Initiatives including Value Based Purchasing, Pay for Performance, and Readmission criteriaEnsuring documentation aligns with regulatory requirements, coding standards, and healthcare policiesConducts regular audits to assess the quality of clinical documentation and identifying areas for improvementParticipates in quality improvement initiatives related to clinical documentation and coding accuracyUse, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standardsLimit viewing of PHI to the absolute minimum as necessary to perform assigned dutiesUnderstand and comply with Information Security and HIPAA policies and procedures at all timesQualificationsMinimum of 3 years of experience in inpatient clinical documentation improvement role requiredMinimum of 5 years of nursing experience in adult acute care experience in med/surg, critical care, emergency, or PACU requiredCertification minimum requirement – RN, CCDS and/or CDIPCurrent state Registered Nursing license required.Coding credential highly preferred (CCS, CPC, CCS-P)Current state Registered Nurse license highly preferredClinic Fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement SystemsDemonstrated skills in analytical thinking, problem solvingExcellent communication and people skillsSelf-motivated and able to work independently without close supervisionProficient in the use of computers including Microsoft Office (Word, Excel, PowerPoint, etc.), Outlook, and other applications necessary to perform the CDS role such as an encoder or CDI workflow and reporting toolWorking ConditionsPhysical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear. Perform light lifting (up to 15 pounds)Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stressWork Environment: Works in a well-lighted/ventilated office setting. Subject to frequent interruptions. Minimal occupational exposure to infectious diseases, blood borne pathogens, hazardous chemicals, noxious odors, latex, or musculoskeletal injuries. Operate Office machines properly and in accordance with Hospital safety standards. Ability to work in accordance with Hospital Safety StandardsMed-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.

About the Company

Med-Metrix

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