Specialist I - Inpatient Clinical Documentation Integrity (ICDI)

Mayo Clinic•Rochester, MN

About The Position

Reviews inpatient and/or outpatient medical records to ensure accurate representation of severity of illness. Validates that clinical documentation supports medical necessity of services and accurate coding. Ensures documentation reflects patient’s clinical status, risk of mortality, and care complexity. Applies advanced knowledge of disease processes, pathophysiology, medications, and critical thinking to identify and remedy documentation gaps. Identifies opportunities for improvement in concurrent and retrospective documentation. Ensures compliance with regulatory standards related to documentation, coding, and billing. Collaborates with physicians, coders, case managers, nurses, and other staff to improve documentation quality. Acts as an educator and resource to clinical staff, promoting best practices in documentation. Acts as a change agent for improved documentation and enhanced documentation practices. May perform ICDI DRG Secondary Reviews as well as support audit related activities. Maintains compliance with ethical, legal, and coding standards.

Requirements

Associate’s degree
2 years of experience as an Inpatient Clinical Documentation Improvement Specialist (CDIS)
Certified Documentation Improvement Practitioner (CDIP) OR Certified Clinical Documentation Specialist (CCDS) certification

Nice To Haves

Demonstrates strong analytical thinking and problem-solving skills.
Communicates effectively, both verbally and in writing, with physicians, leadership, and interdisciplinary teams.
Self-motivated with the ability to work independently and without close supervision.
Works collaboratively in a dynamic, team-oriented environment.
Must be able to work flexible hours, including evenings and weekends, as needed to meet business demands.

Responsibilities

Reviews inpatient and/or outpatient medical records to ensure accurate representation of severity of illness.
Validates that clinical documentation supports medical necessity of services and accurate coding.
Ensures documentation reflects patient’s clinical status, risk of mortality, and care complexity.
Applies advanced knowledge of disease processes, pathophysiology, medications, and critical thinking to identify and remedy documentation gaps.
Identifies opportunities for improvement in concurrent and retrospective documentation.
Ensures compliance with regulatory standards related to documentation, coding, and billing.
Collaborates with physicians, coders, case managers, nurses, and other staff to improve documentation quality.
Acts as an educator and resource to clinical staff, promoting best practices in documentation.
Acts as a change agent for improved documentation and enhanced documentation practices.
May perform ICDI DRG Secondary Reviews as well as support audit related activities.
Maintains compliance with ethical, legal, and coding standards.