A Brief Overview

The Clinical Documentation Integrity Specialist is responsible for utilizing independent clinical judgement in facilitating the integrity, overall quality, accuracy and completeness of provider-based clinical documentation in the medical record. This position is responsible for collaborating with healthcare providers to ensure the documentation in the medical record accurately reflects the patient complexity and resource utilization. The CDI Specialist assesses the clinical documentation through extensive review of the medical record, interacts with multiple members of the healthcare team, educates and assists the clinical areas in effective and compliant documentation. The CDI Specialist provides guidance with processes in the clinical departments to support accurate, timely and complete documentation in agreement with company policies and procedures.

What You Will Do

• 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 complexity and resource utilization. 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
  • Query writing is AHIMA compliant per practice briefs 
  • Escalates non-response to query by physicians immediately according to query escalation policy
  • Collaborates with the coding team
  • Demonstrates proficiency in reviewing increasingly complex cases.
  • Demonstrates proficiency and efficiency in cross covering for other units, specialties and hospitals as assigned.
• 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
  • Participates in service line rounding/touch-point routinely.
  • 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. 
  • Identifies opportunity utilizing resources and follows department guidelines for processes
  • Comprehends the impact of accurate clinical documentation in the medical record: accurate billing, public reporting, research data, quality metrics, provider scorecards, etc.
• Meets established operational and productivity standards.
  • Consistently meets productivity, quality, and ethical standards. 
  • Proficient and efficient use of the CDI business platform
• • Serves as a mentor to other Clinical Documentation Specialists, participates in committees

Additional Responsibilities

• Amendment for Inpatient Clinical Documentation Specialist • Performs review of facility inpatient encounters to ensure hospital case-mix index and severity profiles are accurate by performing timely medical record review, determination of working DRG assignment and applying clinical expertise to identify opportunities for improved or clarified documentation that accurately reflects the severity of illness and risk of mortality of the patient. Direct and timely follow-up with clinical providers to ensure requested clarification is provided. • Demonstrates proficiency in establishing and reconciling DRG processes compliant with departmental guidelines and CMS regulations. • Demonstrates proficiency in reviewing increasingly complex (SOI and ROM) cases. • Participates in service line rounding/touch-point routinely, based on facility needs. • Identifies HAC/PSI query opportunity utilizing resources and follows department guidelines for HAC/PSI query processes • Comprehends the impact of accurate clinical documentation in the medical record beyond establishing a working DRG: accurate billing, public reporting, research data, quality metrics, provider scorecards, accuracy of the UHDDS, Case Mix Index (CMI). • Demonstrates skills of high efficiency and accuracy to identify and reduce DRG downgrades/denial risks by assuring that clinical support is beyond dispute for DRG integrity, coding and billing needs
• Amendment for Outpatient Clinical Documentation Specialist • Performs review of facility outpatient encounters identified as potentially missing charges and conducts additional research to help resolve the areas of opportunity and identify the root cause of the issues causing the missed charges. • Coordinates with clinical departments including Coding, CDM, Finance and others to review, correct claims and identify root cause of missing charges. • Performs analysis of patient clinical and billing data to identify documentation, coding and charging opportunities, summarizes data and prepares summary materials for discussion with clinical and finance teams. • Develops and maintains project plans and project tracking, including documentation of project meetings and project issues lists. • Work with finance to track revenue indicators and corresponding action plans. • Auditing and monitoring of defined areas.
• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.