Clinical Documentation Integrity Specialist

Job Summary

Administers the Clinical Documentation Integrity program for a single site. Using project management, clinical knowledge and knowledge of coded data for documentation requirements to improve overall patient quality, capture severity, acuity and risk of mortality. Applies expertise to ensure the clinical documentation required for the completeness of patient records using a multidisciplinary and interdisciplinary team process.  Collaborates with coders on a daily basis.  In addition, works in conjunction with and supports Hospital and Support Center staff to reach goals and objectives of the program.

Essential Functions

• Implements and provides oversight for a single Clinical Documentation Integrity Program in an organized and standardized manner.
• Participates in mentoring and training new clinical documentation Integrity staff.
• Establishes effective working relationships with the hospital and Support Center staff.
• Facilitates appropriate clinical documentation to support, identify and validate all of the appropriate diagnoses. 
• Identifies and reviews principle and secondary diagnosis and complications to ensure diagnosis specificity. Also identifies and reviews for POA (Present on Admission), Hospital Acquired Conditions (HACs) documentation and initiates a communication clarification process when appropriate with providers.
• Reviews clinical issues with medical coding staff and with physicians to identify those diagnoses that impact severity of illness indicators for each patient. Serves as an expert resource in reviewing all medical records in support of consistent documentation for all payer types (i.e. CMS, Medicare-Advantage, RACs, etc) to ensure complete and accurate diagnosis capture and coding.
• Collaborates in the development of programs, initiatives and workflows, which provide alignment with education for internal customers to support clinical documentation guidelines.
• Collaborates with Case Management leaders, HIM staff and clinical teams routinely as predicated on business need.
• Conducts quality assurance reviews on the CDI processes and functions, and reports results to hospital leadership.
• Compiles information and reports to the Physician Advisor/Medical Director and committees as deemed necessary.  
• Provides CDI education related to clinical documentation opportunities for improvement as well as potential DRG migration opportunities to hospital clinical and leadership teams.
• Conducts data and root cause analysis; provides feedback and shares findings on the analysis to hospital leaders and medical team.
• Leads the “Query process” to medical staff for accurate clear documentation in the patient’s medical records. Monitors and tracks verbal and written queries and produces reports as required.
• Serves on committees and work groups as needed and as appropriate.
• In collaboration with facility administrative team, determine content, audience and venue of education

Knowledge/Skills/Abilities/Expectations

• Has expert interpersonal, communication (verbal, non-verbal, and listening skills). Strong ability to present to hospital leadership and clinical committees on the importance of documentation improvement and effectiveness
• Understands Adult Learning Theory.
• Understands coding classifications systems such as, but not limited to ICD-10 CM, MS-DRG, APR-DRGs, and HCCs strongly preferred.
• Has the ability to combine clinical knowledge and business acumen to deliver results with a track record of assessing and capitalizing on opportunities for streamlining operations through broad based experience in project leadership and process reengineer
• Must exhibit efficiency, collaboration, candor, openness, and results orientation.
• Has knowledge of the healthcare revenue cycle.
• Has competent computer skills including word processing, spreadsheets, and presentation software.
• Must have strong analytical skills. Demonstrate an understanding of the operations and/or business of Scion Healthcare Hospitals, health policy trends, and any applicable regulations related to the responsible practice area.
• Approximate percent of time required to travel: up to 50%, predicated on business need
• Must Read, write and speak fluent English.
• Must have good and regular attendance.
• Performs other related duties as assigned. 

Education

• Associate’s or Bachelor’s degree from an accredited school of nursing, Health Information Management, and/or medicine or healthcare undergraduate/graduate degree required. 
• Master’s Degree is preferred.

Licenses/Certification

• CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Integrity Practitioner) certification is required after 2 years of being in this role. 

Experience

• 3-4 years clinical experience (i.e. inpatient, clinical documentation, and/or case management reviews). 
• Prior Clinical Documentation Integrity experience preferred.