Job Purpose

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. The Clinical Documentation Integrity Specialist performs 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 to facilitate appropriate coding. The Clinical Documentation Integrity Specialist utilizes advanced knowledge of disease processes, medications, and has critical thinking to analyze current documentation to identify gaps in clinical documentation.

Duties & Responsibilities

• Analyze medical records to identify incomplete, inconsistent, or inaccurate documentation related to diagnoses, treatments, procedures, severity of illness, and risk of mortality
• Perform concurrent chart reviews to ensure clinical documentation accurately reflects the patient's condition, complexity of care, and services rendered to support appropriate coding and reimbursement
• Facilitate clarification and modification of clinical documentation through concurrent interaction with physicians and members of the healthcare team to ensure accurate representation of patient severity and DRG assignment
• Periodically analyze coding and documentation data to identify trends, variations, and opportunities for documentation improvement, and communicate findings to management
• Utilize data analytics, DRG reports, and tracking tools to monitor documentation performance, identify gaps, and support performance improvement initiatives
• Collaborate with physicians, nurses, coders, and other healthcare professionals to clarify documentation and obtain additional information necessary for accurate and compliant coding
• Provide support to coding teams by ensuring documentation supports code assignment and complies with coding guidelines and regulatory requirements
• Communicate effectively with coding staff and healthcare providers to resolve coding-related issues and promote documentation accuracy and consistency
• Conduct training and educational sessions for providers and staff on documentation best practices, coding guidelines, compliance requirements, and quality initiatives, as requested by CDI leadership
• Demonstrate knowledge of quality measure initiatives, including Value-Based Purchasing, Pay-for-Performance, readmission reduction programs, and related regulatory requirements
• Ensure clinical documentation aligns with organizational policies, coding standards, regulatory requirements, and payer guidelines
• Conduct routine audits and reviews of clinical documentation to evaluate quality, accuracy, and compliance, and identify opportunities for improvement
• Participate in quality improvement initiatives focused on enhancing clinical documentation integrity, coding accuracy, and operational performance
• Other duties as assigned
• Use, protect and disclose patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards

• Understand and comply with Information Security and HIPAA policies and procedures at all times
• Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties

• BSN or PA (Physician's Assistant) or NP (Nurse Practitioner) or Doctorate degree in a medically related field required
• High school diploma or equivalent required
• Minimum of 3 years of experience in clinical documentation improvement role required
• Minimum of 5 years nursing experience in adult acute care in med/surg, critical care, emergency, or PACU required
• Active RN, MD, DO, NP, or PA license required
• Certification minimum requirement - CCDS and/or CDIP
• Coding credential (CCS, CPC, CCS-P) is a plus
• Current state Registered Nurse license highly preferred
• Clinic fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems
• Proficient in CDI tools such as encoder or CDI workflow and reporting tool
• Proficiency in Microsoft Office Suite
• Strong interpersonal skills, ability to communicate well at all levels of the organization
• Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses
• High level of integrity and dependability with a strong sense of urgency and results oriented
• Excellent written and verbal communication skills required

• Must possess a smart-phone or electronic device capable of downloading applications, for multifactor authentication and security purposes
• Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear
• Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress
• Work Environment: The noise level in the work environment is usually minimal