University Hospitals Pain Management
Clinical Documentation Integrity Specialist II (Remote) ($5K sign on)
University Hospitals Pain Management, Shaker Heights, Ohio, United States
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 collaborates with healthcare providers to ensure the documentation in the medical record accurately reflects 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 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
Ensure documentation is accurate and complete by performing timely medical record reviews and determining code assignments by applying clinical and/or coding expertise to identify opportunities for improved or clarified documentation that accurately reflects patient complexity and resource utilization. Direct and timely follow-up with clinical providers to ensure requested clarification is provided. Expand CDI and coding knowledge, keeping up to date on latest research, technology, treatment modalities, etc. Utilize critical thinking and problem-solving processes. Appropriately utilize and interpret professional association resource materials and regulatory agency guidelines to enhance own skill sets: Coding Clinics, AHIMA, CMS guidelines. Identify query opportunities for record integrity and maintain proficiency in query writing so that the question is easily understood by the physician. Ensure query writing is AHIMA compliant per practice briefs. Escalate non-response to query by physicians immediately according to query escalation policy. Collaborate with the coding team and demonstrate proficiency in reviewing increasingly complex cases. Demonstrate proficiency and efficiency in cross-covering for other units, specialties and hospitals as assigned. Additional Responsibilities
Amendment for Inpatient Clinical Documentation Specialist: Review facility inpatient encounters to ensure hospital case-mix index and severity profiles are accurate by performing timely medical record review, determining working DRG assignments and identifying opportunities for improved or clarified documentation that accurately reflects severity of illness and risk of mortality. 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 ensuring that clinical support is beyond dispute for DRG integrity, coding and billing needs. Amendment for Outpatient Clinical Documentation Specialist: Review facility outpatient encounters identified as potentially missing charges and conduct additional research to help resolve areas of opportunity and identify the root cause of missed charges. Coordinate with clinical departments including Coding, CDM, Finance and others to review, correct claims and identify root causes of missing charges. Perform analysis of patient clinical and billing data to identify documentation, coding and charging opportunities, summarize data and prepare materials for discussion with clinical and finance teams. Develop and maintain 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. Audit and monitor 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 patients. Annual training, the UH Code of Conduct and UH policies and procedures address appropriate use of PHI in the workplace.
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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 collaborates with healthcare providers to ensure the documentation in the medical record accurately reflects 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 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
Ensure documentation is accurate and complete by performing timely medical record reviews and determining code assignments by applying clinical and/or coding expertise to identify opportunities for improved or clarified documentation that accurately reflects patient complexity and resource utilization. Direct and timely follow-up with clinical providers to ensure requested clarification is provided. Expand CDI and coding knowledge, keeping up to date on latest research, technology, treatment modalities, etc. Utilize critical thinking and problem-solving processes. Appropriately utilize and interpret professional association resource materials and regulatory agency guidelines to enhance own skill sets: Coding Clinics, AHIMA, CMS guidelines. Identify query opportunities for record integrity and maintain proficiency in query writing so that the question is easily understood by the physician. Ensure query writing is AHIMA compliant per practice briefs. Escalate non-response to query by physicians immediately according to query escalation policy. Collaborate with the coding team and demonstrate proficiency in reviewing increasingly complex cases. Demonstrate proficiency and efficiency in cross-covering for other units, specialties and hospitals as assigned. Additional Responsibilities
Amendment for Inpatient Clinical Documentation Specialist: Review facility inpatient encounters to ensure hospital case-mix index and severity profiles are accurate by performing timely medical record review, determining working DRG assignments and identifying opportunities for improved or clarified documentation that accurately reflects severity of illness and risk of mortality. 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 ensuring that clinical support is beyond dispute for DRG integrity, coding and billing needs. Amendment for Outpatient Clinical Documentation Specialist: Review facility outpatient encounters identified as potentially missing charges and conduct additional research to help resolve areas of opportunity and identify the root cause of missed charges. Coordinate with clinical departments including Coding, CDM, Finance and others to review, correct claims and identify root causes of missing charges. Perform analysis of patient clinical and billing data to identify documentation, coding and charging opportunities, summarize data and prepare materials for discussion with clinical and finance teams. Develop and maintain 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. Audit and monitor 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 patients. Annual training, the UH Code of Conduct and UH policies and procedures address appropriate use of PHI in the workplace.
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