Clinical Documentation Integrity Specialist

Texas Health Resources • Arlington, TX

1d • Remote

About The Position

The Clinical Documentation Integrity Specialist is responsible for concurrently analyzing medical records to facilitate improvement in the overall quality and completeness of the medical record documentation to ensure accurate depiction of the level of clinical services provided and to completely describe the patient's acuity and severity of illness. This involves extensive record review, interaction with physicians, HIM professionals, and other ancillary staff. Active participation in team meetings and ongoing education of staff in the complete, accurate and compliant documentation process is a key role.

Requirements

• Associate’s degree in nursing required or Bachelor’s degree in nursing required or Associates degree in HIM or other healthcare related field required or Bachelor’s degree in HIM or other healthcare related field required
• 2 years related clinical experience (Quality, Risk, Compliance, UM, Case Management, etc) required or 5 years acute care hospital inpatient coding required
• RN upon hire required or RHIT, RHIA, CCS or other ( CCSP, CIC, COC, CPC, CCDS, CDIP) upon hire required

Responsibilities

• Accurate and timely record review: By enrolling and reviewing available new inpatients every day except weekends and holidays with re-reviews approximately every two days until the patients are discharged. Processing discharged patients utilizing the reconciliation process.
• Recognize opportunities for documentation improvement: By using strong critical thinking skills, and medical knowledge of disease processes with an exceptional ability to integrate knowledge. Ability to analyze complex clinical information to identify areas within the medical record for potential gaps in physician documentation. Identifies opportunities to justify the intensity of service and severity of illness, and shares this information in an interdisciplinary approach with physicians and staff, with the goal of obtaining documentation excellence supporting the care provided to the patient.
• Formulate clinically credible and compliant documentation clarifications: By utilizing the compliant clarification format and clinically credible indicators, sign/symptoms, risk factors, and treatment. Responsible for developing appropriate physician clarification tools and processes in accordance within Medicare (CMS), AHIMA and THR guidelines.
• Effective and appropriate communication with physicians: By providing necessary feedback and clinically credible clarifications with the ability to communicate clearly, proactively, and concisely when interacting with physicians. Provide education to physicians and other clinical providers to ensure their understanding of the clarification process and the desired outcome of documentation excellence for severity of illness and intensity of care. Providing feedback and education in proficient verbal and written formats.
• Timely follow up on all cases especially those with clinical documentation clarifications: Reviews accounts with open clarifications daily and seeks to obtain a documented answer for the clarifications before the patient is discharged. Performs subsequent reviews on all other accounts regularly through discharge, to ensure a thorough and quality review. Is able to prioritize work flow, demonstrates a strong ability to mulit-task, proactively prioritizes initiatives and effectively manages resources. Provides follow-up with providers to open clarifications up to 7 days post-discharge to obtain query response.
• Accurate input of data into software system: Utilize established guidelines after reconciling with the final coded data two to three times per week. Ensuring CDI database is maintained in a current fashion within expected timeliness guidelines.
• Communicates with management staff and resolve discrepancies: By identifying the opportunities and provide rationale with supported clinical criteria such as pathology of disease processes, diagnostic findings, lab values, and signs/symptoms and/or coding guidelines when applicable and forward such discrepancies to management staff in a timely manner for resolution. Participates in the analysis and trending of statistical data to identify opportunities for improvement. Identifies strategies for work process changes that facilitate complete, accurate clinical/physician documentation.

Benefits

• 401k
• PTO
• medical
• dental
• Paid Parental Leave
• flex spending
• tuition reimbursement
• student Loan forgiveness

What This Job Offers

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