Clinical Documentation Integrity Specialist

Clinical Documentation Integrity Specialist

Position Summary

The Clinical Documentation Integrity Specialist is responsible for the concurrent review of inpatient records for timely, accurate, and complete physician documentation. This position requires the ability to work independently and complete self-directed tasks of record reviews, physician queries, and analytics reporting. Candidate must have a strong clinical background and the ability to critically analyze complex cases and effectively communicate with providers and staff. Knowledge of DRG and coding compliance as well as awareness of regulatory environment is necessary to succeed.

Education

Associate's in Nursing - Required

Experience

3-5 Years Acute Care Clinical experience - Required

5-7 Years Acute Care Clinical experience - Preferred

License & Certification

Registered Nurse License with State of Practice - Required

ACDIS Certified Clinical Documenation Specialist (CCDS) or AHIMA Certified Doumentation Improvement Practitioner (CDIP) - Required at time of offer or when eligible per Association criteria

Core Job Functions

• Perform concurrent review of patient records analyzing clinical status, current treatment and past medical history to identify potential gaps in physician documentation. Conduct follow-up reviews, craft compliant clinical clarification queries to assist physicians to provide more detailed information. Establish positive relationships with the clinical team and conduct ad hoc education on documentation and coding issues.
• Responsible for creating and presenting specific clinical topics to the medical providers, clinical staff and HIM team. Research and disseminate information on quality measures (AHRQ & APR-DRG metrics). Coordinate with Coding Manager on developing a library of compliant queries.
• Maintain the documentation program database using the 3M program to complete work sheets. Update work sheets and reconcile with final coding. Collaborate with HIM to review DRG audits to develop and implement strategies for denials management and improvement of quality outcomes, reimbursement and financial outcomes.
• Prioritize case load on a daily basis. Illustrate the ability to take initiative and good judgment in a self directed role.
• Attends educations sessions including in-person, written or webinar. Maintains required credential(s) and continuing education requirements.

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