Clinical Documentation Integrity (CDI) Analyst (Remote)

University Hospitals • Shaker Heights, OH

9d • Remote

About The Position

The Clinical Documentation Integrity (CDI) Analyst applies clinical expertise and knowledge of healthcare workflows to educate and train CDI Specialists, improve the accuracy and completeness of medical record documentation, and support accurate reporting of quality outcomes. The analyst teaches CDI Specialists about coding and clinical documentation integrity rules and regulations, trains new hires, provides ongoing coaching, and ensures CDI staff work is accurate and compliant. The role collaborates with CDI leadership and Coding to identify training opportunities and educate CDI and Coding staff on clinical documentation and coding scenarios.

The analyst conducts post-discharge, final-coded, pre-bill second-level reviews of targeted records to identify opportunities to accurately capture patient acuity, severity of illness, risk of mortality, and DRG assignment in compliance with industry rules and regulations. The role documents findings, places and follows up on physician queries when documentation opportunities are identified, and coordinates with coders or Coding Leadership when coding opportunities arise. The analyst also supports CDI Specialists with challenging concurrent reviews, provides feedback and education, tracks trends and opportunities, reviews second-level review criteria, and contributes to department quality, process improvement, and enterprise CDI initiatives.

The position requires a diploma in nursing or health information management, an associate's or bachelor's degree preferably in nursing or health information management, or a doctorate in medicine. At least three years of experience as a concurrent CDI reviewer is required. Required credentials include an Ohio and/or multistate compact RN license, RHIA, or RHIT, together with CCDS or CDIP certification. International medical doctor education and experience may qualify in place of RN, RHIA, or RHIT. The role is remote and includes a stated travel requirement of 10%25.

Requirements

• At least 3 years of CDI experience as a concurrent reviewer.
• Diploma in Nursing or Health Information Management, or an associate's or bachelor's degree preferably in Health Information Management or Nursing, or a doctorate degree in medicine.
• Ohio and/or multistate compact Registered Nurse (RN) license, Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT), required upon hire.
• Certified Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement Practitioner (CDIP), required upon hire.
• International medical doctor education and experience may meet qualifications in lieu of RN, RHIA, or RHIT.
• Extensive clinical knowledge and understanding of pathology and physiology, preferably demonstrated through clinical experience in a hospital setting.
• Strong critical-thinking skills and ability to identify information supported by clinical indicators or clues but not yet documented in the medical record.
• Understanding of Case Mix Index (CMI), including interpreting and analyzing data, explaining trends and impacting factors, and developing strategies to correct or optimize CMI.
• Knowledge of age-specific patient needs, disease processes, and related procedures.
• Excellent written and verbal communication skills, including concise and effective communication with providers.
• Assertiveness to facilitate ongoing physician communication.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-oriented environment and as part of a team, primarily in a virtual setting.
• Maintain professional knowledge through reading and/or attending webinars related to Clinical Documentation Improvement.
• Earn and maintain Clinical Documentation Improvement certification.
• Incorporate current literature, research, and best practices from ACDIS and AHIMA into daily practice.
• Up-to-date clinical and coding experience and current working knowledge of pathology, pharmacology, surgical procedures, and related subjects.
• Detail-oriented and organized, with strong time-management, analytical, and problem-solving skills.
• Strong client service, communication, presentation, and relationship-building skills.
• Comply with all policies and standards and securely protect patient PHI.

Responsibilities

• Conduct post-discharge, final-coded, pre-bill second-level reviews of targeted records to identify opportunities to accurately capture acuity, severity of illness, risk of mortality, and DRG assignment in compliance with industry rules and regulations.
• Document second-level review findings in the CDI application.
• Place physician queries and follow up for responses when documentation opportunities are identified.
• Coordinate with coders and/or Coding Leadership to review and address coding opportunities.
• Serve as a role model, resource, and subject matter expert for CDI team members.
• Respond to CDI Specialist requests for concurrent chart reviews on challenging cases, providing recommendations and supporting rationale.
• Perform concurrent second-level reviews based on defined criteria and share feedback with the assigned CDI Specialist regarding identified opportunities.
• Maintain a summary of opportunities identified through second-level reviews for CDI team feedback and education.
• Coordinate with other Second Level Reviewers, CDI Leads, and the CDI Educator to compile trends and conduct individual and group education.
• Periodically review second-level review criteria and recommend updates or modifications.
• Perform targeted audits in support of department initiatives.
• Participate in quality initiatives such as HAC/PSI and US News/Mortality.
• Collaborate with CDI Leadership, Leads, and Educators to optimize query templates.
• Identify and share workflow improvement opportunities found during the second-level review process.
• Facilitate change and support the CDI team through change-management processes.
• Engage in advancing CDI practice across the UH enterprise and participate in department and/or enterprise-wide committees.
• Perform other duties as assigned and comply with applicable policies and standards.
• Safely and securely maintain patients' Protected Health Information (PHI) and comply with related training, the UH Code of Conduct, and UH policies and procedures.

Benefits

• $5,000 sign-on bonus

What This Job Offers

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