Lead Clinical Documentation Integrity Specialist

Adventist Health • Bakersfield, CA

8d • $69 - $94

About The Position

The Lead Clinical Documentation Integrity Specialist engages with physicians through meetings and ad hoc interactions to strengthen relationships between the Clinical Documentation Integrity team and providers. The role manages, reviews, evaluates, and assesses patient medical records for specificity of illness, accuracy of clinician documentation, coding requirements, and documentation of important medical details, supporting the quality and completeness of the record and compliance with government and other regulations. The position runs programs with moderate budget or impact and participates in assigned committees.

The specialist serves as a liaison among medical staff, other departments, and the CDI team; attends onsite meetings to represent CDI; trains new hires; runs reports; and conducts denials reviews when required. The role primarily supports an assigned market and may support other markets in the region as needed. It also analyzes medical records, formulates physician queries, communicates documentation deficiencies and conflicting information to providers, and collaborates with physicians and department staff to ensure accurate clinical information, diagnoses, and severity capture. The specialist monitors regulatory changes related to documentation and coding and communicates them to appropriate staff, following applicable documentation guidelines and legal requirements.

Requirements

• Associate's/Technical Degree or equivalent combination of education and related experience required.
• Bachelor's degree or equivalent combination of education and related experience required.
• Five years of clinical documentation integrity experience required.
• Three years of clinical experience required.
• Current licensed RN, medical provider, or equivalent required.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (DIP) certificate required within two years of hire.

Responsibilities

• Engage with physicians in meetings and ad hoc interactions to promote working relationships between the CDI team and providers.
• Manage, review, evaluate, and assess patient medical records for illness specificity, documentation accuracy, coding requirements, and important medical details.
• Act as a liaison among medical staff, other departments, and the CDI team, relaying feedback and representing CDI at onsite meetings.
• Train new hires and run reports.
• Review denials when required.
• Support the assigned market and other regional markets as needed.
• Analyze and interpret medical records and clinical documentation, and formulate appropriate physician queries.
• Identify conflicting data and communicate documentation deficiencies to healthcare providers to resolve conflicts.
• Collaborate with physicians and department staff to ensure medical records contain accurate clinical information and capture appropriate diagnoses and severity for services rendered.
• Monitor regulatory changes related to documentation and coding and communicate updates to appropriate staff.
• Follow documentation guidelines and legal requirements to ensure compliance with federal and state regulatory bodies.
• Run programs with moderate budget or impact and participate in assigned committees.
• Perform other job-related duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior