Clinical Document Integrity Specialist

Savista • Remote - CA, CA

3d • $85,000 - $90,000

About The Position

The Clinical Document Integrity Specialist (CDIS) will facilitate modifications to clinical documentation through extensive concurrent chart review and interactions with physicians and other clinicians. The goal is to ensure accurate documentation of diagnoses and procedures, reflect appropriate clinical severity, clarify complications and conflicting documentation, and capture co-morbid conditions. The CDIS will complete the majority of concurrent reviews to evaluate selected patient medical records for overall quality and completeness. This role also involves educating physicians, non-physician clinicians, nurses, and coding staff on ongoing documentation opportunities, coding and reimbursement issues, and relevant quality and performance improvement opportunities. The CDIS will assist the team in meeting and exceeding high-performing CDI program metrics.

Requirements

• Licensed as a Registered Nurse with an Associate Degree (ADN) or Bachelor’s degree in Nursing (BSN), or an MD OR Credentialed as an RHIA, RHIT, CPC, or CCS and have experience in ICD 10 coding.
• At least three (3) years of recent acute care nursing experience required OR At least three (3) years of clinical coding and/or auditing experience in a hospital environment.
• Clinical expertise required.
• Computer PC literacy required.
• Excellent communicator, negotiator and have great organizational skills.
• Strong knowledge of clinical documentation guidelines required.
• Able to work collaboratively and independently.
• Flexible with responsibilities in order to meet departmental needs.
• Able to demonstrate initiative and the ability to work in a fast-paced environment with proficiency in multi-tasking and prioritization.
• Experience in computerized hospital/health information management systems and software applications are required.

Nice To Haves

• ICU or ED experience preferred.
• Certification in Clinical Documentation Integrity (CCDS, CDIP) strongly desired.
• Certified in coding (CCS) preferred.
• Technical knowledge of ICD-10, DRG and APR assignment and prospective payment methodologies preferred.
• Detail oriented, ability to work independently, exercise good judgment and be resourceful.
• Proficient communication skills, both written and verbal.
• Able to speak clearly and concisely while presenting.
• Ability to write reports independent of management review is a plus.
• Experience and/or knowledge of regulatory compliance issues facing the healthcare industry is also a plus.
• Strong interpersonal skills to work with key stakeholders, physicians and/or clients and staff to implement positive/effective change.
• Demonstrated customer-oriented management style.
• Ability to manage execution by balancing time, resources, and quality constraints to achieve goals required.
• Focused on team and collaboration.
• Ability to address critical issues and demonstrate self-initiation.
• Ability to think critically and analytically, anticipate challenges and trends.
• Computer knowledge of MS Office, including Word, Excel, and PowerPoint is preferred.
• Working knowledge of automated system designs is preferred.

Responsibilities

• Utilize extensive knowledge of documentation requirements and guidelines in accordance with Coding Clinic to improve the overall quality and completeness of clinical documentation by performing concurrent stay reviews.
• Utilize client technology to track documentation notes and observations, assign Working DRG and calculate Query DRG to reflect impact of queries initiated, complete query entry for tracking purposes and complete validation process to ensure diagnosis located in EMR or attained by query are final coded.
• Educate internal staff on clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues and conduct follow up reviews of clinical documentation to ensure points clarified with the physician have been recorded in the patient’s record.
• Follow established workflows and processes developed for Clinical Documentation Integrity, Strategic Source.
• Compose and initiate AHIMA compliant queries.
• Utilize client CDI technology and follow established standardized process flow.
• Maintain open communication with coding to discuss DRG assignment, diagnosis, clinical indicators, coding clinics and guidelines and educating each other on specialty.
• Assign Working DRG for Case Management department to view Length of Stay (LOS) of patients.
• Participate and provide input regarding CDI program activities, and attendance at routine team meetings.
• Maintain current skill set with regard to government regulations, compliance and reimbursement guidelines.
• Keep abreast of new legislation and regulations that affect CDI.
• Maintain personal and professional education and growth.
• Responsible for maintaining continuing education credits as required by credentialing organization.

Benefits

• Salary range of $85,000.00 to $90,000.00

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree