Role Description The Clinical Documentation Integrity Specialist focuses on the accuracy, completeness and consistency of inpatient clinical documentation to support coding and reporting of high-quality healthcare data. This role involves: - Performing concurrent chart reviews to validate that the clinical documentation in the medical record appropriately describes the patient’s severity of illness, complexity of care, and risk of mortality. - Utilizing advanced knowledge of disease processes and medications to analyze current documentation and identify gaps. - Facilitating appropriate modifications to documentation through extensive interactions and collaborations with providers, coding, quality, and case management teams. - Serving as an effective change agent and educator for providers and interdisciplinary care teams. Qualifications - Minimum of 3 years of experience in inpatient clinical documentation improvement role required. - Minimum of 5 years of nursing experience in adult acute care (med/surg, critical care, emergency, or PACU) required. - Certification minimum requirement – CCDS and/or CDIP. - Current state Registered Nursing license required. - Coding credential highly preferred (CCS, CPC, CCS-P). - Current state Registered Nurse license highly preferred. - Fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems. - Demonstrated skills in analytical thinking and problem solving. - Excellent communication and people skills. - Self-motivated and able to work independently without close supervision. - Proficient in the use of computers including Microsoft Office (Word, Excel, PowerPoint, etc.), Outlook, and other applications necessary to perform the CDS role. Requirements - Analyzes medical records to identify incomplete or inaccurate documentation related to diagnoses, treatments, and procedures. - Periodically analyzes coding data to identify documentation variations and determine the cause and appropriateness of such variation; presents findings to management. - Works closely with healthcare professionals to clarify and obtain additional information needed for accurate documentation. - Facilitates modification to clinical documentation supporting the clinical picture/level of severity rendered to all patients. - Collaborates with healthcare providers and stakeholders to clarify and improve documentation. - Provides support to medical coders by ensuring documentation supports the assigned codes and compliance with coding guidelines. - Communicates effectively with coding teams to address coding-related issues and promote accurate code assignment. - Conducts training sessions for healthcare staff on proper documentation practices, coding guidelines, and compliance requirements. - Utilizes data analytics to identify trends, patterns, and areas for improvement in documentation accuracy and completeness. - Monitors daily DRG assignment, DRG reports, and tracking areas for performance improvement. - Demonstrates an understanding of current Quality Measure Initiatives including Value Based Purchasing, Pay for Performance, and Readmission criteria. - Ensures documentation aligns with regulatory requirements, coding standards, and healthcare policies. - Conducts regular audits to assess the quality of clinical documentation and identify areas for improvement. - Participates in quality improvement initiatives related to clinical documentation and coding accuracy. - Uses, protects, and discloses patients’ protected health information (PHI) only in accordance with HIPAA standards. - Limits viewing of PHI to the absolute minimum necessary to perform assigned duties. - Understands and complies with Information Security and HIPAA policies and procedures at all times. Company Description