Clinical Documentation Integrity Specialist
Clinical Documentation Integrity Specialist
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Salary Not Disclosed
1 Vacancy
Job Description
Heres What You Need
- Associates degree in nursing required or
- Bachelors degree in nursing required or
- Associates degree in HIM or other healthcare related field required
- Bachelors degree in HIM or other healthcare related field required
- 2 years related clinical experience (Quality Risk Compliance UM Case Management etc) required or
- 5 years acute care hospital inpatient coding required
- RNupon hire required or
- RHIT RHIA CCS or other ( CCSP CIC COC CPC CCDS CDIP) upon hire required
What You Will Do
The Clinical Documentation Integrity Specialist is responsible for concurrently analyzing medical records to facilitate improvement in the overall quality and completeness of the medical record documentation to ensure accurate depiction of the level of clinical services provided and to completely describe the patients acuity and severity of involves extensive record review interaction with physicians HIM professionals and other ancillary participation in team meetings and ongoing education of staff in the complete accurate and compliant documentation process is a key role.
Accurate and timely record review:
By enrolling and reviewing available new inpatients every day except weekends and holidays with re-reviews approximately every two days until the patients are discharged patients utilizing the reconciliation process.
Recognize opportunities for documentation improvement:
By using strong critical thinking skills and medical knowledge of disease processes with an exceptional ability to integrate knowledge. Ability to analyze complex clinical information to identify areas within the medical record for potential gaps in physician documentation. Identifies opportunities to justify the intensity of service and severity of illness and shares this information in an interdisciplinary approach with physicians and staff with the goal of obtaining documentation excellence supporting the care provided to the patient.
Formulate clinically credible and compliant documentation clarifications:
By utilizing the compliant clarification format and clinically credible indicators sign/symptoms risk factors and treatment. Responsible for developing appropriate physician clarification tools and processes in accordance within Medicare (CMS) AHIMA and THR guidelines.
Effective and appropriate communication with physicians:
By providing necessary feedback and clinically credible clarifications with the ability to communicate clearly proactively and concisely when interacting with physicians. Provide education to physicians and other clinical providers to ensure their understanding of the clarification process and the desired outcome of documentation excellence for severity of illness and intensity of feedback and education in proficient verbal and written formats.
Timely follow up on all cases especially those with clinical documentation clarifications:
Reviews accounts with open clarifications daily and seeks to obtain a documented answer for the clarifications before the patient is discharged. Performs subsequent reviews on all other accounts regularly through discharge to ensure a thorough and quality review. Is able to prioritize work flow demonstrates a strong ability to mulit-task proactively prioritizes initiatives and effectively manages follow-up with providers to open clarifications up to7 days post-discharge to obtain query response.
Accurate input of data into software system:
Utilize established guidelines after reconciling with the final coded data two to three times per week. Ensuring CDI database is maintained in a current fashion within expected timeliness guidelines.
Communicates with management staff and resolve discrepancies:
By identifying the opportunities and provide rationale with supported clinical criteria such as pathology of disease processes diagnostic findings lab values and signs/symptoms and/or coding guidelines when applicableand forward such discrepancies to management staff in a timely manner for resolution. Participates in the analysis and trending of statistical data to identify opportunities for improvement. Identifies strategies for work process changes that facilitate complete accurate clinical/physician documentation.
Additional perks of being a Texas Health Clinical Documentation Integrity Specialist
- Benefits include 401k PTO medical dental Paid Parental Leave flex spending tuition reimbursement student Loan forgiveness as well as several other benefits.
- Delivery of high quality of patient care through nursing education nursing research and innovations in nursing practice.
- Strong Unit Based Council (UBC).
- A supportive team environment with outstanding opportunities for growth.
- Learnmore about our culture benefits and recent awards.
Do you still have questions or concernsFeel free to email your questions to.
#LI-LD1
Clinical Documentation Integrity Specialist
Bring your passion to Texas Health so we are Better Together
Work location:Remote
Work hours:Monday Friday from 8am 5pm
Department highlights:
- 100% remote work
- Flexible hours/scheduling
- Terrific work/life balance
Required Experience:
Unclear Seniority
Employment Type
Full-Time
