Inpatient Clinical Documentation Integrity Specialist

Valleywise Health • Phoenix, AZ

10h • Hybrid

About The Position

The Clinical Documentation Integrity Specialist uses clinical and nursing knowledge of documentation requirements to improve the quality and completeness of patient-record documentation through a multidisciplinary team process. The role works collaboratively with physicians to ensure clinical information in the medical record is present and accurate, and partners with Coding to support appropriate severity-of-illness and risk-of-mortality documentation.

The specialist interacts with physicians and ancillary staff, providing education regarding documentation clarification. The role also collaborates with hospital departments to support documentation requirements related to medical necessity, admission, continuity of patient care, and other clinical matters. The position offers a hybrid work schedule with regular in-office attendance; candidates must be within commuting distance and comfortable working in a physical office setting weekly.

Requirements

• Associate's degree in Nursing, Health Information Technology, or a related field, or an equivalent combination of training and progressively responsible experience resulting in the required specialized knowledge and abilities.
• At least three years of recent clinical nursing, Coding, or clinical documentation experience demonstrating the required knowledge, skills, and abilities.
• Current, valid AZ RN or LPN license, or valid compact RN or LPN licensure for the current state of practice, or certification as a RHIA, RHIT, CCS, CCS-P, CPC, CIC, or COC.
• Must obtain Certified Clinical Documentation Specialist (CCDS) certification within 30 months of hire.
• Exceptional critical-thinking and communication skills and a strong clinical knowledge base.
• Effective interpersonal skills to interact with Providers.
• Analytical skills to interpret medical-record documentation and formulate appropriate Provider queries.
• Knowledge of anatomy and physiology, pathophysiology, pharmacology, AHA Coding Clinic, and AHIMA Query Practice Brief guidelines.
• Knowledge of MS and APR-DRGs, DRG assurance, Coding, Revenue Cycle, and Midas.
• Basic computer word-processing skills and ability to navigate an electronic medical record using a computer.
• Ability to read, write, and speak effectively in English.
• Must be within commuting distance and comfortable attending a physical office weekly.

Nice To Haves

• Bachelor's degree in Nursing, Health Information Administration, or a related field.
• Clinical documentation improvement specialist experience or training.
• Experience as a Critical Care, Trauma, Pediatric, NICU, or Burn Registered Nurse.
• Hands-on experience using the 3M / Solventum encoder.
• Experience working with APR DRGs, mortality reviews, and Hospital-Acquired Conditions (HACs) / Patient Safety Indicators (PSIs).

Responsibilities

• Improve the quality and completeness of clinical documentation in patient records through a multidisciplinary team process.
• Collaborate with physicians to ensure clinical information in the medical record is present and accurate.
• Work with Coding to support appropriate severity-of-illness and risk-of-mortality documentation.
• Interact with physicians and ancillary staff and provide education regarding documentation clarification.
• Collaborate with hospital departments on documentation supporting medical necessity, admission, continuity of patient care, and other clinical requirements.
• Interpret medical record documentation and formulate appropriate Provider queries when increased specificity is needed to clarify, link, or establish diagnoses, conditions, and procedures.
• Benchmark and analyze clinical documentation program performance.

What This Job Offers

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