Clinical Documentation Integrity Liaison
About The Position
The Clinical Documentation Integrity (CDI) Liaison improves the quality, completeness, and accuracy of medical record documentation. The role serves as a liaison among the CDI team, Coding team, providers, and other relevant parties; conducts ongoing, quality assurance, ad hoc, and special-project reviews; compiles review summaries and presentations; teaches CDI and coding concepts; and interprets clinical information in relation to CDI and coding. The Liaison applies advanced knowledge to develop recommendations and education, helps ensure compliance with regulatory requirements and institutional policies, and keeps current with CDI and coding guidance and developments. The position reviews records and queries physicians using the approved process, participates in clinical validation denial reviews and other value-measurement and financial-sustainability projects, and adheres to ethical coding standards and applicable guidelines. It works with physicians, advanced practice providers, allied health practitioners, case managers, dieticians, and other care-team members to gather accurate clinical information for abstraction. The Liaison performs inpatient and outpatient CDI in assigned settings, supporting accurate diagnosis and coding documentation, including HCC capture, ICD-10-CM specificity, and medical necessity for ambulatory visits and treatments. The role also educates care-team members on documentation guidelines, coding requirements, and service-specific requirements, and helps train and orient new CDI team members. It may conduct concurrent reviews when specialist coverage is needed. Responsibilities are allocated as follows: 60% documentation improvement, including record audits, review findings, data integrity, coding, and reimbursement-related work; 30% quality assurance and team support, including query monitoring and serving as a subject-matter expert; and 5% education and training, including provider education and other CDI-related duties. The job description does not specify the remaining time allocation.
Requirements
- Current RN license and a bachelor's degree in nursing; or an RN license and a bachelor's degree in Health Information Management or another related field; and/or graduate education leading to a PA degree with PA license; and/or graduate education leading to an MD, DO, or equivalent degree.
- ACDIS Certified Clinical Documentation Specialist (CCDS).
- Experience with ICD-10-CM/PCS coding and DRG assignment.
- At least 2 years of relevant clinical documentation improvement experience.
- At least 2 years of demonstrated clinical experience in an acute-care setting.
- Excellent written and oral communication skills and interpersonal skills.
- Competency with Microsoft Office, including PowerPoint, Word, and Excel.
Nice To Haves
- Master’s degree in nursing with an advanced practice license and congruent acute-care experience.
- AHIMA Certified Coding Specialist (CCS).
Responsibilities
- Conduct ongoing, quality assurance, ad hoc, and special-project reviews requiring advanced CDI knowledge and review skills.
- Act as a liaison among the CDI team, Coding team, providers, and other relevant parties to facilitate clinical documentation improvements.
- Compile and organize review summaries and deliver concise presentations as requested.
- Review records and query physicians using the approved query process to obtain clinical information.
- Participate in clinical validation denial reviews and value-measurement or financial-sustainability projects.
- Interact with physicians, advanced practice providers, allied health practitioners, case managers, dieticians, and other care-team members to gather accurate and timely information for abstraction.
- Perform inpatient and outpatient CDI with physicians and advanced practice providers in assigned settings to ensure diagnoses and coding are accurately represented in the medical record.
- Support documentation for HCC capture, ICD-10-CM specificity, and medical necessity of ambulatory visits and treatments.
- Educate care-team members about documentation guidelines, coding requirements, and service-specific requirements.
- Audit medical records and coded data to identify opportunities related to DRG optimization, severity of illness, risk of mortality, length of stay, and documentation quality.
- Record, summarize, and communicate review details and findings to the manager.
- Ensure medical-record abstract data is accurate and complete before billing interface and claims submission; partner with Patient Accounts and Finance to resolve coding and reimbursement issues.
- Perform clinical record abstracting and data collection to support reimbursement, data quality, performance-improvement analysis, and outcome reporting.
- Assign and sequence ICD-10-CM diagnosis and procedure codes and/or CPT codes in compliance with UHDDS, billing requirements, and organizational policies.
- Assist the CDI manager with quality assurance reviews of clinical documentation staff.
- Monitor and validate queries for necessity, accuracy, and compliance; contribute feedback about CDI specialist performance and evaluation.
- Serve as a departmental subject-matter expert and resource to CDI specialists, and collaborate with the Coding team to resolve CDI-related questions and issues.
- Create and/or deliver CDI-related education and training to providers, CDI staff, and coders.
- Participate in training and orientation of new CDI team members.
- Perform concurrent CDI reviews when clinical documentation specialist coverage is needed.
- Remain current on CDI and coding developments, official guidelines, guidance updates, and trends, and apply this knowledge to work practices.
- Follow applicable departmental and institutional policies and procedures, meet performance standards, and use resources effectively.
- Perform other CDI-related duties as requested.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
