Clinical Documentation Integrity (CDI) Specialist II (Remote)

Description The Clinical Documentation Integrity Specialist is responsible for utilizing independent clinical judgement in facilitating the integrity, overall quality, accuracy and completeness of provider-based clinical documentation in the medical record. This position is responsible for collaborating with healthcare providers to ensure the documentation in the medical record accurately reflects the patient complexity and resource utilization. The CDI Specialist assesses the clinical documentation through extensive review of the medical record, interacts with multiple members of the healthcare team, educates and assists the clinical areas in effective and compliant documentation. The CDI Specialist provides guidance with processes in the clinical departments to support accurate, timely and complete documentation in agreement with company policies and procedures. What You Will Do Ensure documentation is accurate and complete by performing timely medical record review and determination of code assignment, applying clinical and/or coding expertise to identify opportunities for improved or clarified documentation that accurately reflects the patient complexity and resource utilization. Continue to follow up with clinical providers to ensure requested clarification is provided. Responsible for expanding CDI and coding knowledge. Utilize critical thinking and problem solving processes. Appropriately utilize and interpret professional association resource materials and regulatory agency guidelines. Identify query opportunities for record integrity. Proficient in query writing so that the question is easily understood by the physician. Queries are AHIMA compliant per practice briefs. Escalate non-response to query by physicians immediately according to query escalation policy. Collaborate with the coding team. Demonstrate proficiency reviewing increasingly complex cases. Provide proficiency and efficiency in cross covering for other units, specialties and hospitals as assigned. Actively engage in educating physicians and other clinical care providers regarding clinical documentation in a variety of formats including participation in clinical rounding, service line focused education sessions and one-to-one case specific feedback. Consistently provide a collaborative relationship with healthcare team members. Participate in service line rounding/touch-points routinely. Provide ongoing service line directed education to provider teams. Apply knowledge of healthcare workflows to improve overall accuracy and comprehensiveness of medical record documentation, with focus on ensuring accurate reporting of quality outcomes. Seek and provide feedback for improved CDI practice and integrity/quality of medical record documentation. Identify opportunities using resources and follow department guidelines for processes. Comprehend impact of accurate clinical documentation on billing, public reporting, research data, quality metrics, provider scorecards, etc. Meet established operational and productivity standards. Consistently meet productivity, quality, and ethical standards. Proficient and efficient use of the CDI business platform. Serve as a mentor to other Clinical Documentation Specialists, participate in committees. Additional Responsibilities Amendment for Inpatient Clinical Documentation Specialist: Perform review of facility inpatient encounters to ensure hospital case-mix index and severity profiles are accurate, determine DRG assignment, identify opportunities for improved documentation, follow up with clinical providers for clarification, demonstrate proficiency in DRG processes, and handle HAC/PSI query opportunities. Comprehend impact on billing, reporting and accuracy of metrics. Amendment for Outpatient Clinical Documentation Specialist: Perform review of outpatient encounters potentially missing charges, conduct research to resolve missed charges, coordinate with coding, CDM, finance and other departments, analyze patient clinical and billing data, develop and maintain project plans, track revenue indicators, audit and monitor defined areas. Perform other duties as assigned. Comply with all policies and standards. For specific duties and responsibilities, refer to documentation provided during orientation. Abide by all requirements to safely and securely maintain PHI for our patients; annual training, UH Code of Conduct and UH policies and procedures are in place for appropriate use of PHI. #J-18808-Ljbffr