Clinical Documentation Integrity Specialist
University Hospitals
full-time
Posted on:
Location Type: Remote
Location: Ohio • United States
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About the role
- Ensures documentation is accurate and complete by performing timely medical record review and determination of code assignment by applying clinical and/or coding expertise to identify opportunities for improved or clarified documentation that accurately reflects the patient.
- Direct and timely follow-up with clinical providers to ensure requested clarification is provided.
- Responsible and accountable for expanding CDI and coding knowledge (keeping up to date on latest research, technology, treatment modalities, etc.)
- Utilizes critical thinking/problem solving processes.
- Appropriately utilizes and interprets professional association resource materials and regulatory agencies guidelines to enhance own skill sets: Coding Clinics, AHIMA, CMS guidelines.
- Identifies query opportunities for record integrity.
- Is proficient in query writing so that the question is easily understood by the physician.
- Escalates non-response to query by physicians immediately according to query escalation policy.
- Collaborates with the coding team.
- Actively engages in educating physicians and other clinical care providers regarding clinical documentation in a variety of formats including participation in clinical rounding, service line focused education sessions and one to one case specific feedback.
- Consistently provides a collaborative relationship with healthcare team providers/members.
- Provides ongoing service line directed education to provider teams.
- Applies knowledge of health care workflows in order to work collaboratively with medical staff and other health care team members to improve the overall accuracy and comprehensiveness of medical record documentation, with focus on ensuring accurate reporting of quality outcomes.
- Seeks and provides feedback for improved CDI practice and integrity/quality of medical record documentation.
- Meets established operational and productivity standards.
- Consistently meets productivity, quality, and AHIMA ethical standards.
- Proficient and efficient use of the CDI business platform.
Requirements
- Associate's Degree in health related field (Required) or Other Accredited Program: Diploma in Nursing (Required)
- Bachelor's Degree in health related field (Preferred)
- 3+ years clinical and/or ICD-10 coding experience, preferably in a large academic medical center (Required)
- 1+ years Experience using clinical computer systems (Required)
- Previous CDI experience (Preferred)
- Must have thorough, up-to-date clinical skills (i.e. current working knowledge of pathology, pharmacology, surgical procedures, etc.). (Required proficiency)
- Excellent written and verbal communication skills including presentations. (Required proficiency)
- Ability to function independently and as a team player in a fast-paced environment. (Required proficiency)
- Detail-oriented, and relationship building skills. (Required proficiency)
- Demonstrates and has extensive knowledge of disease pathophysiology (Required proficiency)
- Registered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire) or Registered Health Information Administration (RHIA) (Required Upon Hire) or Registered Health Information Technologist (RHIT) (Required Upon Hire)
Benefits
- Complies with all policies and standards.
- Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
ICD-10 codingclinical documentation improvement (CDI)query writingclinical skillsdisease pathophysiologymedical record reviewcoding expertisecritical thinkingproblem solvinghealth care workflows
Soft Skills
written communicationverbal communicationpresentation skillsindependenceteam playerdetail-orientedrelationship buildingcollaborationeducational skillsfeedback provision
Certifications
Registered Nurse (RN)Ohio LicenseMulti State Compact LicenseRegistered Health Information Administration (RHIA)Registered Health Information Technologist (RHIT)