Lead - Inpatient Clinical Documentation Integrity (ICDI)
About The Position
The Lead - Inpatient Clinical Documentation Integrity (ICDI) reviews inpatient and/or outpatient medical records to ensure accurate representation of severity of illness, medical necessity, clinical status, risk of mortality, and complexity of care. The role applies advanced knowledge of disease processes, medications, coding, and clinical documentation to identify gaps and opportunities for improvement, while ensuring compliance with regulatory, ethical, legal, and coding standards. The Lead collaborates with physicians, coders, case managers, nurses, and other staff to improve documentation quality, clarify documentation, and support accurate coding, risk adjustment, value-based care, and reimbursement. The role provides education and guidance to clinical staff and may conduct DRG secondary reviews, mortality reviews, audit and denial work, and quality improvement projects. The position also provides work direction and assistance to employees, supports orientation and training, acts as a liaison between staff and the supervisor, and helps ensure that work is completed appropriately. Flexible hours, including evenings and weekends, may be needed to meet business demands.
Requirements
- Associate’s degree and 7 years of experience as an Inpatient Clinical Documentation Improvement Specialist (CDIS), or a bachelor’s degree and 5 years of experience as an Inpatient Clinical Documentation Improvement Specialist (CDIS).
- Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) certification.
- Certified Coding Specialist (CCS) AHIMA certification or Certified Inpatient Coder (CIC) AAPC certification.
- Certified Risk Adjustment Coder (CRC) AAPC certification.
- Excellent written and verbal communication skills.
- Strong teamwork, adaptability, and situational awareness.
- Proficiency in Word, PowerPoint, and Excel.
- Project management and problem-solving skills.
- Strong attention to detail and excellent organizational skills.
- Flexibility with work hours to meet business needs.
Nice To Haves
- Familiarity with OneNote, SharePoint, and Copilot.
Responsibilities
- Review inpatient and/or outpatient medical records to ensure accurate representation of severity of illness.
- Validate that clinical documentation supports medical necessity and accurate coding.
- Ensure documentation reflects the patient's clinical status, risk of mortality, and complexity of care.
- Apply advanced knowledge of disease processes, medications, and critical thinking to identify documentation gaps.
- Identify opportunities to improve concurrent and retrospective documentation.
- Ensure compliance with regulatory standards related to documentation, coding, and billing, as well as applicable ethical, legal, and coding standards.
- Collaborate with physicians, coders, case managers, nurses, and other staff to improve documentation quality and coding accuracy.
- Educate and serve as a resource to clinical staff, promoting documentation best practices.
- Act as a change agent for improved and enhanced documentation.
- Perform ICDI DRG secondary reviews as needed and support audit- and denial-related activities.
- Perform special projects and quality improvement initiatives; may conduct secondary mortality reviews.
- Apply CCS or CIC expertise to assign inpatient codes accurately and in accordance with coding guidelines.
- Use CRC expertise to capture chronic conditions accurately in inpatient documentation and support risk adjustment and value-based care initiatives.
- Review clinical records to identify and validate chronic conditions that affect patient risk scores and reimbursement.
- Initiate counseling with staff regarding work quality, productivity, and team communication for corrective action or performance improvement plans.
- Act as liaison between staff and supervisor; communicate information and work assignments and carry out special assignments as requested.
- Provide work direction and assistance to other employees and ensure work in the area of responsibility is properly completed.
- Participate in orientation and training of new employees.
- Maintain effective communication with physicians, leadership, and interdisciplinary teams.
- Work flexible hours, including evenings and weekends, as needed to meet business demands.
Benefits
- Multiple medical plan options.
- Dental coverage through Delta Dental or a reimbursement account for flexible coverage.
- Affordable vision plan with a national network.
- HSA and FSA pre-tax savings options for eligible expenses.
- Competitive retirement package.
- Continuing education and advancement opportunities.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
Associate degree
