Clinical Documentation Specialist

Clinical Documentation Specialist

Position Details:

Full Time - Remote

Reports to the National Director, Clinical Documentation Integrity

Must reside in one of the States listed below to be eligible for this position:

Arkansas    California    Kentucky

Massachusetts Nevada    New Mexico

Oregon     Utah     Tennessee

Texas     Wyoming

Job Summary:

The Clinical Documentation Integrity Specialist (CDIS) provides clinically based, concurrent and retrospective reviews of all inpatient medical records. CDI Specialists strive to ensure accurate, complete, compliant, concise and consistent documentation that reflects the true clinical scenario of the patient's encounter. This additionally serves to reflect the true Severity of Illness (SOI), Risk of Mortality (ROM), and Intensity of Services (IOS) rendered to provide quality care and treatment to the patient. The Clinical Documentation Integrity Specialist serves as a liaison between leadership, medical staff, nursing, coding, case management and quality departments. Excellent communication skills and the ability to critically analyze are essential to successful CDI performance.

Duties and Responsibilities:

• Provides clinically based, concurrent and retrospective reviews of inpatient medical records. Ensures documentation accurately reflects quality of care, severity of illness and risk of mortality to support compliant coding, reimbursement, quality reporting, and denials prevention initiatives.

• Proactively contacts physicians or other clinicians as needed to clarify procedures/diagnoses to ensure proper documentation. This includes providing information for physicians and other clinical staff in educational sessions.

• Performs initial case reviews and follow up reviews. More experienced CDI Specialists will perform PSI/HAC, retrospective and second level reviews.

• Submits compliant provider queries as needed to clarify documentation of relevant diagnoses, procedures, clinical indicators, present-on-admission status, acuity, specificity, and treatment in accordance with ACDIS/AHIMA compliant query guidance and organizational policy.

• Applies knowledge of ICD-10-CM/PCS Official Guidelines for Coding and Reporting, AHA Coding Clinic, MS-DRG/APR-DRG methodology, CC/MCC capture, SOI/ROM, and quality indicators to support an accurate working DRG in collaboration with Coding/HIM.

• Promotes a partnership with Coding/HIM team to ensure the accuracy of principal diagnosis, procedures, and completeness of documentation to determine the working and final DRG, severity of illness and risk of mortality. Functions as a liaison between clinical and coding teams.

• Actively engages and participates in delivery of education to providers through extensive interaction one on one

• Promotes collaboration and engagement with physicians to support query education.

• Utilizes critical thinking skills and clinical reasoning to identify, clarify, and query accurate representation of documentation to reflect appropriate clinical status of the patient which will translate into quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending.

• Maintains professional competency in documentation and coding practices by keeping up to date with new coding guidelines, policies/procedures, federal and state reimbursement.

• Communicates effectively with the multidisciplinary team consisting of physicians, nurses, coders, administration and others.

• All tasks must be performed in accordance with the established Quorum CDI daily workflow with adherence to Inpatient CDI Handbook protocols.

• Communicates in a timely manner with CDI leadership, reporting potential and/or actual problems. Responds timely to emails and requests in a professional and courteous manner.

• Follows Quorum query escalation process to address query response results that are untimely, missing, or inappropriate.

• Meets or exceeds CDI performance minimal standards:

• 15 reviews per 8 hours worked

• 30% (encounters impacted by) query rate

• 93% query compliance in accordance with ACDIS/AHIMA compliant query guidance and organizational policy

• 20 % missed query opportunity 95% accuracy and in a timely manner for reconciliation

• Consistently demonstrates proficiency in engaging with providers in areas such as education, query follow-up, and virtual or in-person interactions through scheduled encounters.

• Proficiently perform second level reviews as assigned (special project focused reviews, etc.).

• Actively mentor newer CDI Specialists through onboarding, side by side teaching and consistently being available as a resource to less experienced CDI Specialists.

• Meet or exceed all above-listed duties

• More experienced and proficient CDI Specialists:

• Perform all the above functions with minimal supervision and optimal accuracy and efficiency.

Knowledge, Skills and Abilities:

• Must possess strong organizational, communication, clinical reasoning, coding guideline, and documentation integrity foundation skills.
• Must demonstrate proficiency in EMR software, CDI applications (after education and orientation) and Microsoft applications.
• Demonstrates ability to multi-task and work efficiently and effectively between software platforms.
• Demonstrates the ability to communicate effectively in a fast-paced environment with multidisciplinary teams consisting of physicians, nurses, coders, administration and other health care professionals.
• Demonstrates proficiency in CDI process after completion of onboarding and orientation/education. Continued improvement in proficiency and accuracy is expected during and after orientation/onboarding.
• Experienced CDI Specialists are expected to onboard more quickly and meet performance metrics commensurate with their experience level.
• Ability to work independently, prioritize tasks and demonstrates self-awareness as to when to seek assistance.

Work Experience, Education and Certifications:

• Education: Bachelor's degree in Nursing, Health Information Management, healthcare administration, or related healthcare field is preferred. Associate degree/diploma, allied health education, or equivalent professional credential may be considered with demonstrated CDI, clinical, coding, or HIM experience.
• Experience: 2-5 years acute care clinical, inpatient coding, HIM, quality, utilization review/case management, or revenue cycle experience preferred. Inpatient CDI experience and knowledge of IPPS, MS-DRGs, CC/MCCs, SOI/ROM, HAC/PSI, and denials prevention preferred. More experienced CDI Specialists will be expected to attain CDI certification. Job assignments will align with experience, qualifications and expertise.
• Certification/Licensure: Current unrestricted RN, LPN/LVN, or other applicable clinical license required only when candidate is hired under that clinical credential. RHIA, RHIT, CCS, CCDS, CDIP, MD/DO/MBBS, foreign medical graduate, or other qualified healthcare/coding credential may be considered when supported by demonstrated clinical documentation and coding knowledge. CCDS or CDIP preferred and encouraged; experienced CDI Specialists should obtain CCDS or CDIP within 24 months of meeting eligibility requirements or hire, unless otherwise approved by CDI leadership.

Benefits:

• Competitive salary and benefits package.
• Opportunities for professional development and advancement.
• Supportive work environment with a collaborative team.
• Comprehensive healthcare coverage.
• Retirement savings plan.
• Paid time off and flexible scheduling options.
• Student loan repayment program.