Clinical Documentation Integrity Specialist 2
Clinical Documentation Integrity Specialist 2
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Salary Not Disclosed
1 Vacancy
Job Description
Inova Health System is looking for a dedicatedClinical Doc Integrity Specialist 2to join the team. This role will be full-time day shift from Monday Friday.
This position is eligible for remote work for candidates residing in the following states VA MD DC DE FL GA NC OH PA SC TN TX WV.
Inova is consistently ranked a national healthcare leader in safety quality and patient experience.We are also proud to be consistently recognized as a top employer in both the D.C. metro area and the nation.
Featured Benefits:
- Committed to Team Member Health:offering medical dental and vision coverage and a robust team member wellness program.
- Retirement:Inova matches the first 5% of eligible contributions starting on your first day.
- Tuition and Student Loan Assistance:offeringup to $5250 per year in education assistance and up to $10000 for student loans.
- Mental Health Support:offering all Inova team members their spouses/partners and their children 25 mental health coaching or therapy sessions per person per year at no cost.
- Work/Life Balance:offeringpaid time off paid parental leave flexible work schedules and remote and hybrid career opportunities.
Clinical Doc Integrity Spec 2 Job Responsibilities:
- Performs initial case reviews and an appropriate number of follow-up reviews based on program standards. Uses clinical insight and judgment of clinical findings to assess clinical documentation for improvement opportunities. Independently develops complex queries. Follows up with the physician responsible for the care of the patient via the query process for clarification of clinical significance and appropriate documentation.
- Maintains query rate response rate and agreement rate in line with established performance benchmarks.
- Assists with reviewing records at different Inova hospitals as needed and under the supervision of assigned CDI leaders.
- Participates in all department-wide CDI and coding education on ICD-10 MS-DRG and quality outcome measures as well as compliance requirements related to query (AHIMA Practice brief).
- Maintains competency in the use of CDI applications to process daily work lists and report results of record reviews and queries.
- Enters all required data into CDI applications to enable Coding professionals and Coding Quality Coordinators to determine the disposition of concurrent queries in order to assign the final MS-DRG as well as APR-DRG SOI and ROM and risk adjustment factors. Demonstrates expert knowledge of ICD 10 codes and MS-DRG/APR DRG assignments.
- Interacts with Coding Quality Coordinators and Coding professionals on any questions related to CDI working DRG related to concurrent queries and final coding.
- Assists with any post-discharge (retrospective) queries per CDI policy/procedure and as requested by CDI leadership.
- Demonstrates advanced technical ability with current software used by the department.
- Provides electronic support to providers regarding best practice documentation standards and the query process. Provides 1:1 provider education within the daily workflow and participates in group education sessions as requested by CDI Leadership.
- Participates in special projects audits and other duties as directed by CDI Leadership. May assist with precepting and education of new staff.
- Works collaboratively with medical nursing and ancillary staff to improve the quality of chart documentation that assures appropriate DRG classification to accurately reflect patient severity of illness and risk of mortality.
- Participates and takes a leadership role in select special projects audits and other duties as directed by CDI Leadership.
- As needed may travel across the Washington DC metro area to engage with providers.
Minimum Qualifications:
- Education:Associate Degree (RN MD RHIA/RHIT)
- Experience:
- Five years of professional inpatient acute care inpatient clinical and/or coding experience required. Includes ICU ER Peds/NICU case management/UR quality or similar level of advanced care/coding.
- Two years of CDI experience in an acute inpatient healthcare setting.
- Certification:CDI certification (CCDS or CDIP) ***Preferred CCDS
- Licensure: RN RHIT or foreign medical school licensure documentation equivalent to educational background required.
Required Experience:
Unclear Seniority
Employment Type
Full-Time
