Clinical Documentation Integrity (CDI) Specialist

University Hospitals • Shaker Heights, OH

1d

About The Position

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. 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.

Requirements

• Associate's Degree in health related field (Required) or
• Other Accredited Program: Diploma in Nursing (Required)
• 3+ years clinical and/or ICD-10 coding experience, preferably in a large academic medical center (Required)
• 1+ years Experience using clinical computer systems (Required)
• Must have thorough, up-to-date clinical skills (i.e. current working knowledge of pathology, pharmacology, surgical procedures, etc.). (Required proficiency)
• Excellent written and verbal communication skills including presentations. (Required proficiency)
• Ability to function independently and as a team player in a fast-paced environment. (Required proficiency)
• Detail-oriented, and relationship building skills. (Required proficiency)
• Demonstrates and has extensive knowledge of disease pathophysiology (Required proficiency)
• Registered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire) or
• Registered Health Information Administration (RHIA) (Required Upon Hire) or
• Registered Health Information Technologist (RHIT) (Required Upon Hire)

Nice To Haves

• Bachelor's Degree in health related field (Preferred)
• Prior experience in CDI (Preferred)

Responsibilities

• Ensures documentation is accurate and complete by performing timely medical record review and determination of code assignment by applying clinical and/or coding expertise to identify opportunities for improved or clarified documentation that accurately reflects the patient. Direct and timely follow-up with clinical providers to ensure requested clarification is provided.
• Responsible and accountable for expanding CDI and coding knowledge (keeping up to date on latest research, technology, treatment modalities, etc.)
• Utilizes critical thinking/problem solving processes
• Appropriately utilizes and interprets professional association resource materials and regulatory agencies guidelines to enhance own skill sets: Coding Clinics, AHIMA, CMS guidelines
• Identifies query opportunities for record integrity
• Is proficient in query writing so that the question is easily understood by the physician
• Query writing is AHIMA compliant per practice briefs (Is proficient in query writing so that the question is easily understood by the physician)
• Escalates non-response to query by physicians immediately according to query escalation policy
• Collaborates with the coding team
• Actively engages 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 provides a collaborative relationship with healthcare team providers/members
• Participates in service line rounding/touch-point routinely.
• Provides ongoing service line directed education to provider teams
• Applies knowledge of health care workflows in order to work collaboratively with medical staff and other health care team members to improve the overall accuracy and comprehensiveness of medical record documentation, with focus on ensuring accurate reporting of quality outcomes.
• Seeks and provides feedback for improved CDI practice and integrity/quality of medical record documentation.
• Meets established operational and productivity standards.
• Consistently meets productivity, quality, and AHIMA ethical standards.
• Proficient and efficient use of the CDI business platform
• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees