Quality Impr Clinical Doc Spec / HIM Clinical Document Mgmt

Hartford Healthcare•Farmington, CT

12d

About The Position

The Quality Improvement Clinical Documentation Specialist (QICDS) leads quality and safety documentation initiatives to support medical record optimization, quality of care, and clinical documentation standards. The role requires expertise in medical record review, performance improvement, HIM, coding, CMS requirements, and quality of care standards. The QICDS conducts concurrent and retrospective reviews of potential quality and safety conditions, including Patient Safety Indicators (PSIs), Hospital Acquired Conditions (HACs), and mortality reviews, using relevant software tools. The specialist participates in team meetings and provides ongoing clinical documentation, PSI/HAC, and mortality education to staff and providers. The QICDS may also mentor, train, or lead colleagues during orientation and provide ongoing support with CDI policies, procedures, standard work, and systems. The position works with Coding, Quality, HIM, clinical teams, and organizational leaders to identify documentation opportunities, support compliant coding and quality outcomes, and communicate trends and improvement opportunities. It may include training and special projects, subject matter expertise on regulatory documentation, and other assignments as assigned.

Requirements

Bachelor’s degree in a related field, or an Associate’s Degree in Nursing or progression toward a Bachelor’s Degree.
Registered Nurse (RN) with at least 5 years of recent clinical experience in an acute care hospital, ICU, CCU, strong Med/Surg, or equivalent; alternatively, 2 or more years of Quality Management experience in PSI/HAC and mortality risk systems.
RN license to practice in Connecticut.
Strong written and verbal communication skills.
Ability to learn or develop skills needed to review clinical documentation in medical records.
Knowledge of pathophysiology and disease processes, and working knowledge of clinical information.
Ability to understand and communicate the impact of CC/MCCs and other variables on assignment under various DRG methodologies.
Ability to function independently.
Knowledge of AHRQ Patient Safety Indicator specifications and CMS Hospital-Acquired Conditions.
Solid analytical capabilities and strong organizational, critical-thinking, problem-solving, and deductive-reasoning skills.
Ability to manage multiple priorities and increasing responsibility.
Ability to listen attentively, acknowledge others’ ideas and expressions, communicate clearly in writing and verbally, collaborate toward shared goals, and influence others toward positive and productive outcomes.

Nice To Haves

Master’s degree in Nursing or an associated discipline.
Registered Nurse with 8 or more years of clinical experience in an acute care hospital, ICU, CCU, strong Med/Surg, or equivalent; alternatively, 4 or more years of Quality Management experience in PSI/HAC and mortality risk systems.
Certified Clinical Documentation Specialist (CCDS), Certified Clinical Documentation Professional (CDIP), CPHQ, or other quality certification.

Responsibilities

Review medical records extensively and accurately within specified timelines.
Identify documentation improvement opportunities in records with potential PSIs or HACs and formulate clinically credible, compliant clarifications or queries.
Review mortality records and use software tools to identify appropriate queries and support accurate principal diagnosis, comorbid conditions, severity of illness, risk of mortality, and mortality risk predictors.
Work with Coding and Quality teams and document relevant code, condition, and risk-scoring information in Optum and EPIC for clinical teams.
Perform other clinical documentation reviews as needed.
Follow up on cases, particularly those involving documentation clarifications or queries, and educate providers on query responses and CDI and Quality topics.
Use internal and external data to identify issues and trends affecting patient safety and quality of care; escalate findings and help create and present education to address opportunities.
Perform quality and safety monitoring to support ongoing evaluation of care processes and outcomes.
Meet program quality, productivity, revenue cycle, and KPI standards.
Participate in Coding/CDI meetings and the CDI H3W work group.
Enter review workflows, accurate data, and CDI query impact into Optum and EPIC.
Enter appropriate data into Redcap or other systems for provider review of quality-related outcomes, as needed.
Collaborate with inpatient coders on appropriate DRG and ICD-10 code assignments for compliance, reimbursement, and quality outcomes.
Create training materials and presentations; train and mentor new colleagues.
Serve as a subject matter expert on regulatory documentation, including CMS requirements, and internal policies, procedures, standard work, and workflows.
Seek clarification from physicians, nursing staff, and others when documentation is absent, ambiguous, or contradictory.
Collaborate with HIM coding staff to resolve discrepancies and with Regional Quality Management Teams.
Abide by the Ethical Standards for Clinical Documentation Improvement Professionals established by AHIMA.
Participate in other assignments and special projects as assigned.