Clinical Documentation Integrity Specialist (Remote)

University Hospitals • Shaker Heights, OH

1d • Remote

About The Position

The Clinical Documentation Integrity Specialist uses independent clinical judgment to facilitate the integrity, quality, accuracy, and completeness of provider-based clinical documentation in the medical record. The specialist reviews medical records, collaborates with providers and other healthcare team members, and educates clinical staff to ensure documentation accurately reflects the patient and complies with company policies and procedures. The role also supports timely, complete documentation and accurate reporting of quality outcomes.

Depending on the position assignment, an inpatient specialist reviews facility inpatient encounters, determines working DRG assignments, supports accurate hospital case-mix and severity profiles, reconciles DRG processes, and identifies documentation opportunities related to severity of illness, risk of mortality, HACs, and PSIs. An outpatient specialist reviews encounters potentially missing charges, researches and coordinates resolution with clinical, coding, finance, and CDM teams, analyzes clinical and billing data, develops project plans and tracking materials, monitors revenue indicators, and audits defined areas.

The specialist is expected to meet operational, productivity, quality, and AHIMA ethical standards; comply with applicable policies and CMS regulations; and protect patients’ Protected Health Information. Other duties may be assigned.

Requirements

• Associate's degree in a health-related field or diploma in nursing from an accredited program.
• At least 3 years of clinical and/or ICD-10 coding experience; experience in a large academic medical center is preferred.
• At least 1 year of experience using clinical computer systems.
• Thorough, up-to-date clinical skills, including working knowledge of pathology, pharmacology, and surgical procedures.
• Excellent written and verbal communication skills, including presentation skills.
• Ability to work independently and as a team member in a fast-paced environment.
• Detail orientation and relationship-building skills.
• Extensive knowledge of disease pathophysiology.
• Upon hire, one of the following is required: Ohio and/or Multi State Compact Registered Nurse (RN) license; Registered Health Information Administration (RHIA) credential; or Registered Health Information Technologist (RHIT) credential.

Nice To Haves

• Bachelor's degree in a health-related field.
• Clinical and/or ICD-10 coding experience in a large academic medical center.

Responsibilities

• Review medical records promptly and determine code assignment, identifying opportunities to improve or clarify documentation so it accurately reflects the patient.
• Follow up directly and promptly with clinical providers to obtain requested documentation clarification.
• Identify query opportunities, write clear and AHIMA-compliant queries, and escalate physician non-response according to policy.
• Keep CDI and coding knowledge current, including research, technology, treatment modalities, and applicable professional and regulatory guidance.
• Collaborate with the coding team and healthcare providers.
• Educate physicians and other clinical care providers through clinical rounding, service-line education, and case-specific feedback.
• Work collaboratively with medical staff and healthcare team members to improve documentation accuracy and comprehensiveness and support accurate quality-outcome reporting.
• Seek and provide feedback to improve CDI practice and the integrity and quality of medical record documentation.
• Meet established productivity, quality, operational, and AHIMA ethical standards and use the CDI business platform proficiently.
• For inpatient assignments, review facility inpatient encounters, determine working DRG assignments, support accurate case-mix and severity profiles, reconcile DRG processes, review complex SOI and ROM cases, identify HAC/PSI query opportunities, and help reduce DRG downgrades and denial risks.
• For outpatient assignments, review potentially missed charges, research issues and root causes, coordinate with Coding, CDM, Finance, and clinical departments to review and correct claims, analyze clinical and billing data, prepare summary materials, maintain project plans and tracking, track revenue indicators and action plans with Finance, and audit and monitor defined areas.
• Comply with policies and standards and safely and securely maintain patient Protected Health Information.
• Perform other duties as assigned.

What This Job Offers

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