Lead Clinical Documentation Integrity Specialist

Job Summary

Under the direction of the Corporate Chief Officer, facilitates improvement in the overall quality, completeness and accuracy of medical record documentation for the purposes of ensuring compliance with Medicare, Medicaid (CMS) and Commercial Insurance [on request] regulations and guidelines and to expedite appropriate reimbursement. Collaborates with the Interdisciplinary Care Team to be successful in this role. Utilizes both clinical and diagnostic knowledge, consults with subject matter experts, including ICD-10 coding manager, CDIs, Outcomes, Physiatrists, and Compliance staff, to obtain appropriate documentation through extensive interaction with physicians, nursing and other patient caregivers. Educates all members of the patient care team on documentation guidelines on an ongoing basis. Assists with IRF CMS 60% management, concurrent DRG/CMG/PDPM assignment, diagnosis documentation gaps and ongoing documentation integrity.

Key Responsibilities

• Provides education to the CDI team (IRF, LTCH, SNF) of documentation requirements and notifies the team of coding/billing updates as needed.

• Provides assistance to the CDI team (IRF, LTCH, SNF) for validation of clinical review and development of a compliant physician query.

• Provides education and training to the CDI team (IRF, LTCH, SNF) on Electronic Health Record (EHR) updates.

• Notifies the team of coding/billing updates as needed.

• Maintains and develops Compliant Physician Query Templates located in the Electronic Health Record.

• Assists corporate compliance officer with developing a Metrics reporting system for IRF, LTCH, SNF to assist with financial and data trending reports; Lead CDI provides metrics no less than quarterly.

• Assists the Senior Financial Analyst or other colleague, in developing, maintaining and updating CDI Metrics databases for IRF, LTCH, SN.

• Provides education sessions with the Interdisciplinary Team as requested or when trends demonstrate improvement is needed to ensure compliance with Medicare, Medicaid (CMS) and Commercial Insurance [on request] regulations and guidelines for appropriate financial reimbursement and quality indicators.

• Reviews inpatient medical records within 24-48 hours of admission and throughout hospitalization to:

a) evaluate documentation that supports the coder’s assignment of the reason for admission and/or etiologic diagnosis, principal diagnosis, and comorbidities and complications that support the CMG/DRG/PDPM. This does not include a review of the impairment group code assignment for the IRF.

b) document, review details for trending purposes.

• Conducts concurrent follow up reviews of patients every 2-3 days to support and assign additional diagnoses that may impact length of stay. Queries physicians regarding missing, unclear or conflicting medical record documentation by requesting and obtaining additional documentation within the medical record as applicable

• Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the medical record.

• Collaborates with case managers, nursing staff and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.

• Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.

• Assists the Outcomes Manager/applicable staff with trending, tracking, and educating the Interdisciplinary Team based on external (i.e. PEPPER) and internal data to improve outcomes.

• Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.

• Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis.

• Instructs clinical staff on best practices to ensure accurate documentation in the medical record.

• Maintains and reports clinical documentation improvement results in a clear and concise manner to the medical, clinical, and management staff.

• Applies diplomacy and professionalism when interacting with physicians and clinical staff; especially when addressing missing or conflicting medical record information

• Works in partnership with an interdisciplinary team to foster collaboration, learning and accurate and complete medical record documentation.

• Exhibits skillful, up to date working knowledge of all coding guidelines (Federal and State, etc...) researching websites, publications, and reference materials. Adheres to coding policies and guideline published in “Coding Clinic” and HIM department policies and procedures.

• Collaborates with HIM coding staff, physicians and finance to reduce payment denials, and improve medical necessity documentation.

• Acts as a consultant to providers, management, administration and billing staff regarding documentation, coding, and reimbursement and compliance matters.

• Investigates, evaluates and identifies opportunities for improvement and recognizes their relative significance in the overall system.

• Provides orientation for new clinical staff regarding documentation requirements and coding/billing issues as required.

• Assists in coordinating responses to third party payer audits and/or requests when appropriate; determine the appropriate documentation to be submitted and formulate responses.

• Keeps current with coding scheme changes, proposed and otherwise, through conferences, reference material and review of current literature.

• Maintains confidentiality of all customer/hospital information.

• Demonstrates flexibility in the face of changing work environment, adjusting work schedule accordingly.

• Upholds the Spaulding Rehabilitation Organizational Values of Innovation, Collaboration, Accountability, Respect, and Excellence.

Qualifications and Experience

• Experience working in post-acute care (IRF preferred, SNF or LTCH )

• Graduate of an accredited School of Nursing.

• Current licensure from the Massachusetts Board of Registration to practice professional nursing.

• Certificate in Case Management or Clinical Documentation Improvement (CDIP) preferred.

• Minimum of 5 years’ experience in either clinical nursing, case management, HIM inpatient coding or an equivalent combination of these disciplines.

• Knowledge of acute regulatory/accreditation requirements preferred.

• Basic knowledge of coding/classification systems appropriate for inpatient CMG and DRG prospective payment system

• Computer proficiency required. Microsoft office applications preferred with ability to learn new software.

• High level of service delivery. Demonstrate initiative with ability to prioritize work, meet deadlines and adapt to changing situations.

• Work independently, be self-directed and contribute as a leading member of a team.

• Ability to clearly present information in writing and in presentation form.

• Maintain variable work schedule to meet department needs. (evenings, holidays, weekends and travel).