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 severity of illness and risk of mortality of the patient.  The CDI Specialist assesses the clinical documentation through extensive reviews of the medical record, interaction with all members of the healthcare team, Quality department and the Health Information Management (HIM) Coding team to ensure appropriate coding and DRG assignment for the level of services rendered to the patient and to ensure that the clinical information utilized in profiling and reporting outcomes is complete and accurate.

• Ensures 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.  
  • Responsible and accountable for expanding own nursing and CDI 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, ACDIS, CMS guidelines
  • Identifies concurrent 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 (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 and DRG downgrades teams
  • Demonstrates proficiency in establishing and reconciling DRG processes compliant with departmental guidelines and CMS regulations.  Accurately reconciles all cases in CDI database 95% of the time; determined by quality audit.
  • Demonstrates proficiency in reviewing increasingly complex (SOI and ROM) 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 Integrity 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
  • Spends a minimum of 25% of day on clinical unit(s) networking with providers to establish an effective and collaborative working relationship
  • Participates in service line rounding/touch-point routinely, based on facility needs.
  • 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. 
  • 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).
  • Seeks and provides feedback for improved CDI practice and integrity/quality of medical record documentation.
  • 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
• Meets established operational and productivity standards. 
  • Consistently meets productivity, quality, and AHIMA ethical standards.
  • Proficient and efficient use of the CDI business platform (Streamline-eCDI)

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 severity of illness and risk of mortality of the patient.  The CDI Specialist assesses the clinical documentation through extensive reviews of the medical record, interaction with all members of the healthcare team, Quality department and the Health Information Management (HIM) Coding team to ensure appropriate coding and DRG assignment for the level of services rendered to the patient and to ensure that the clinical information utilized in profiling and reporting outcomes is complete and accurate.

• Ensures 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.  
  • Responsible and accountable for expanding own nursing and CDI 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, ACDIS, CMS guidelines
  • Identifies concurrent 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 (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 and DRG downgrades teams
  • Demonstrates proficiency in establishing and reconciling DRG processes compliant with departmental guidelines and CMS regulations.  Accurately reconciles all cases in CDI database 95% of the time; determined by quality audit.
  • Demonstrates proficiency in reviewing increasingly complex (SOI and ROM) 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 Integrity 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
  • Spends a minimum of 25% of day on clinical unit(s) networking with providers to establish an effective and collaborative working relationship
  • Participates in service line rounding/touch-point routinely, based on facility needs.
  • 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. 
  • 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).
  • Seeks and provides feedback for improved CDI practice and integrity/quality of medical record documentation.
  • 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
• Meets established operational and productivity standards. 
  • Consistently meets productivity, quality, and AHIMA ethical standards.
  • Proficient and efficient use of the CDI business platform (Streamline-eCDI)

Education

• Minimum Associates Degree in health related field or Diploma in nursing required.
• Bachelor’s Degree preferred

Required Credentials, License, and / or Certifications

• Active Registered Nurse (RN) license or 
• Active Registered Health Information Administrator (RHIA) or
• Active Registered Health Information Technician (RHIT) required.

Experience & Knowledge:

•             Minimum 3-5 year’s clinical and/or ICD-10 coding experience, preferably in a large academic medical center, required.  

•             Must have thorough, up-to-date clinical skills (i.e. current working knowledge of pathology, pharmacology, surgical procedures, etc.).

•             Excellent written and verbal communication skills including presentations required.

•             Ability to function independently and as a team player in a fast-paced environment required.   

•             Must be detail-oriented, and relationship building skills required. 

•             Demonstrates and has extensive knowledge of disease pathophysiology

Special Skills & Equipment Knowledge:

•             Demonstrated ability to use PCs, Microsoft Office suite, and general office equipment (i.e., printers, copy machine, FAX machine, etc.) required.

•             Experience using clinical computer systems required.