Career with DextroMedical

Position Summary: This is a full-time remote role for a Clinical Documentation Integrity Specialist Inpatient Consultant. The Specialist will be responsible for reviewing and analyzing clinical documents, ensuring the accuracy of clinical documentation, providing education to healthcare professionals on clinical documentation best practices, and working to enhance hospital operations and Case Mix Index (CMI). Educate physicians, providers, RNs, and other healthcare disciplines on the importance of accurate documentation that reflects the patient population in relation to the severity of illness and risk of mortality. The Specialist will also collaborate with healthcare professionals to ensure precise and thorough clinical documentation, contributing to improved patient care quality and hospital performance. 

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Experience/Qualifications

• Required: A minimum of 2 years recent CDI experience in an acute care setting.

• Preferred: Knowledge of APR-DRG, MS-DRG methodologies and inpatient coding rules and regulations

• Excellent knowledge of medical terminology, coding systems (e.g., ICD-10, CPT), and regulatory requirements (e.g., CMS, Joint Commission)

• Demonstrate knowledge of Microsoft Office

• Strong organizational and communication skills and the ability to work independently

• Experience in Quality Improvement initiatives, and development and implementation of policies, procedures and standards

• Preferred Knowledge of Medicare Advantage and/or Risk Adjustment programs is a plus

• Preferred knowledge in Cerner & 3M 360

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Education

A bachelor’s degree in nursing, a medical doctorate, or a related field is required. 

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Specific Skills, Knowledge, and Abilities Required

• Strong critical thinking skills as they relate to clinical assessment and interpretation of patients lab values, diagnostic studies, treatments and comorbid conditions to understand the clinical presentation of the patient Coding skills with experience in ICD-10-CM and working knowledge of coding guidelines, AHA Coding Clinic,  APR and MS-DRG methodology

• Ability to collect and interpret CDI program data from EHR and monitoring tool (3M 360) to assess progress of the CDI program and areas for growth opportunity.

• Strong organizational skills and ability to multi-task

• The ability to communicate professionally with physicians/providers and other health care disciplines regarding the concepts of CDI and how this impacts our quality, compliance and reimbursement

• Compliance with patient confidentiality requirements and the related legal and ethical issues

• Works collaboratively with the inpatient coders, Case Management HIM department and physicians to ensure a ‘team approach’ to the CDI program

• Excellent interpersonal skills in order to interact effectively with all levels of hospital personnel

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Hospital-Wide Supporting Commitments

• Growth

• Clinical Excellence

• Courtesy/Caring

• Partnership

• Healing Environment​

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Job Responsibilities

1. Demonstrates compliance with Code of Conduct and compliance policies and takes action to resolve compliance questions or concerns and report suspected violations.

2. Performs concurrent review of medical records and identifies areas of documentation requiring clarification of comorbidities, presence of complications and the presence of an opportunity to improve documentation from the physician to accurately assign the best DRG.

3. Reviews 20-25 patient records in assigned areas within 24 hours or first working day after admission and with evidence of ongoing record review at least every 48 hours when necessary. Accomplish 25% query rate of total patients reviewed daily to recover documentation deficiencies. 

4. Compiles data in Excel and maintains monthly and Quarterly records of outcomes that reflect improvement in Clinical Documentation Improvement financial performance. Tracks and reports financial and statistical data in designated system. 

5. Communicates with and works collaboratively with coding personnel to determine outcomes regarding Severity/Complexity and to assure all opportunities have been pursued before patients’ discharge from acute care setting.

6. Educates physicians and staff on Query tool as it relates to quality of documentation in the medical record.

7. Reviews all defined medical records to identify laboratory, radiology, cardiac & pulmonary information, and procedures Pertinent to the patient’s care that is not clearly documented in the medical record.

8. Analyzes deficiencies and educates physicians in need for appropriate documentation to capture the complexity of care and the severity of illness.

9. Implements tracking systems to measure the effectiveness of education.

10. Develops and tracks, in cooperation with the coding department, outcomes related to education and follow-through by physicians regarding accurate complication/comorbidity documentation.

11. Interfaces with physicians regarding educational opportunities for specific documentation with physicians identified as needed additional education.

12. Develops and updates pertinent policies and procedures and processes in collaboration with the Manager of CDI.

13. Obtains daily census and tracks defined admissions and discharges.

14. Maintains compliance to HIPAA and all other regulations related to patient confidentiality.

15. Educate nursing, ancillary, case management staff, and appropriate committees regarding the Clinical Documentation Integrity process and outcomes.

16. Communicate with team members and participate in appropriate committees to report outcome information.

17. Collaborate with the Utilization Management Specialist when continued stay or level of care issues are identified.

18. Assist the HIM department in facilitation of the physician query process after patient discharge.

19. Performs special projects and other duties as directed.