Clinical Documentation Specialist II - HYBRID - Steward Health Care

TITLE: Clinical Documentation Integrity Specialist II
DEPARTMENT: HIM/CDI Operations

POSITION SUMMARY:

The Clinical Documentation Integrity Specialist (CDIS) provides clinically based, concurrent and retrospective reviews of inpatient medical records. CDI strives to ensure accurate, complete, compliant, concise, and consistent documentation that reflects the true clinical scenario of the patients encounter. This additionally serves to reflect the true Severity of Illness (SOI), Risk of Mortality (ROM), and Intensity of Services (IOS) rendered to provide quality care and treatment to the patient. The Clinical Documentation Integrity Specialist serves as a liaison between leadership, medical staff, nursing, coding, case management and quality departments. Excellent communication skills and the ability to critically analyze are essential to successful CDI performance. The CDIS II is an intermediate level position for experienced and proficient CDI Specialists consistently meeting all criteria for CDIS I performance.

KEY RESPONSIBILITIES:

Provides clinically based, concurrent and retrospective reviews of inpatient medical records. Ensures documentation accurately reflects quality of care, severity of illness and risk of mortality to support correct coding, reimbursement, and quality initiatives.
Proactively contacts physicians or other clinicians as needed to clarify procedures/diagnoses to ensure proper documentation. This includes providing information to physicians and other clinical staff.
Performs initial case reviews and follow up reviews as indicated by CDI software. Performs timely and accurate completion of query reconciliation.
Submits queries to providers as needed to ensure complete documentation of relevant diagnoses.
Assigns diagnosis codes following the Official Guidelines for Coding and Reporting and AHA Coding Clinics to obtain an accurate working DRG.
Promotes a partnership with Coding/HIM team to ensure the accuracy of principal diagnosis, procedures, and completeness of documentation to determine the working and final DRG, severity of illness and risk of mortality. Functions as a liaison between clinical and coding teams.
Actively engages and participates in delivery of education to physicians through extensive interaction one on one and in monthly medical staff meetings as needed.
Promotes collaboration and engagement with physicians to support query education.
Utilizes critical thinking skills and clinical reasoning to identify, clarify, and query for accurate representation of documentation to reflect appropriate clinical status of the patient which translates into quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending.
Maintains professional competency in documentation and coding practices by keeping up to date on new coding guidelines, policies/procedures, federal and state reimbursement.
Communicates effectively daily with the multidisciplinary team consisting of physicians, nurses, coders, administration, and others.
All tasks must be performed in accordance with the established Steward CDI daily workflow with adherence to Inpatient CDI Handbook protocols.
Communicates in a timely manner with CDI Manager, reporting potential and/or actual problems identified. Responds timely to emails and requests.
Follows Steward query escalation process to address query response results that are untimely, missing, or inappropriate.
Meets CDI Performance standards of 20 reviews per 8 hours worked, 30% query rate, 95% missed query opportunity, and reconciles all cases with 95% accuracy and in a timely manner. Timely processes reconciliation queue in Iodine and accurately reports query impact.
May be requested to perform other related tasks, record reviews or responsibilities as assigned.
Consistently demonstrates proficiency in engaging with providers in areas such as education, query follow-up, and face to face interactions through scheduled encounters.
Actively mentors newer CDI Specialists through onboarding, side by side teaching and consistently being available as a resource to less experienced CDI Specialists.
May participate and present in facility based medical staff meetings as assigned by CDI Manager.
Proficiently performs second level reviews as assigned (PEPPER reviews, special project focused reviews, etc.).
Performs all the above functions with minimal supervision and optimal accuracy and efficiency.

REQUIRED KNOWLEDGE & SKILLS:

Must possess strong organizational, communication and clinical foundation skills.
Must demonstrate proficiency in EMR software, CDI applications (after education and orientation) and Microsoft applications.
Demonstrates ability to multi-task and work efficiently and effectively between software platforms.
Demonstrates the ability to communicate effectively in a fast-paced environment with multidisciplinary teams consisting of physicians, nurses, coders, administration, and other health care professionals.
Demonstrates proficiency in CDI process after completion of onboarding and orientation/education. Continued improvement in proficiency and accuracy is expected during and after orientation/onboarding.
Experienced CDI Specialists are expected to onboard more quickly and perform commensurate with experience level.
Ability to work independently, prioritize tasks and demonstrate self-awareness in the workplace.
Always maintains confidentiality and HIPAA compliance.

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:
I. Education: Bachelors degree in a clinical or coding study is preferred. Advanced degrees such as Master, Doctorate or Foreign Medical Graduate will require proof of degree status.
II. Experience: Minimum of 2-5 years acute clinical or coding (IP) experience preferred. A minimum of 1 or more years CDI experience required with proficiency consistently demonstrated.
III. Licensure/Certification: RN or LVN with current state license, proof of certification when applicable
IV. Software/Hardware: Proficiency in Microsoft applications, EMR applications, CDI, and coding software