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Clinical Documentation Integrity Specialist
University HospitalsClinical Documentation Integrity Specialist reviewing medical records for compliance and accuracy. Collaborating with healthcare providers and educating on documentation best practices.
About the role
Key responsibilities & impact- 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.)
- 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.
- 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.
- Meets established operational and productivity standards. Consistently meets productivity, quality, and AHIMA ethical standards.
Requirements
What you’ll need- Associate's Degree in health related field (Required) or other Accredited Program: Diploma in Nursing (Required)
- 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)
- 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
Comp & perks- Annual training regarding use of Protected Health Information (PHI)
- Health insurance
- Professional development opportunities
- Paid time off
- Remote work options
ATS Keywords
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Hard Skills & Tools
ICD-10 codingclinical documentation improvement (CDI)medical record reviewclinical expertisepathology knowledgepharmacology knowledgesurgical procedures knowledgeclinical computer systemsdocumentation accuracyquality outcomes reporting
Soft Skills
written communicationverbal communicationpresentation skillsindependent functioningteam collaborationdetail-orientedrelationship buildingeducational engagementfeedback provisionfast-paced environment adaptability
Certifications
Registered Nurse (RN)Ohio LicenseMulti State Compact LicenseRegistered Health Information Administration (RHIA)Registered Health Information Technologist (RHIT)