Clinical Documentation Integrity Analyst
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Job Description
Clinical Documentation Integrity Analyst reviewing hospital records, physician queries, and coding opportunities. Training CDI specialists and improving documentation accuracy, compliance, and quality outcomes at University Hospitals.
Responsibilities:
- Educate and train CDI Specialists in essential role duties to improve accuracy and comprehensiveness of medical record documentation and quality-outcome reporting
- Educate CDI Specialists on coding and clinical documentation integrity rules and regulations
- Train newly hired CDI Specialists and provide ongoing coaching and education on daily job functions
- Ensure Clinical Documentation Integrity staff work output is accurate and compliant
- Collaborate with CDI leadership and Coding team to identify training opportunities and educate CDI and Coding staff
- Perform post-discharge, final coded, pre-bill reviews of targeted records for patient acuity, severity of illness, risk of mortality, and DRG assignment
- Document second-level review findings in the CDI application
- Place physician queries and follow up when documentation opportunities are identified
- Coordinate with coders and Coding Leadership on coding opportunities
- Serve as a role model, resource, and subject matter expert for CDI team members
- Respond to CDS requests for concurrent chart reviews on challenging cases with recommendations and rationale
- Perform concurrent second-level reviews and provide feedback to assigned CDI Specialists
- Maintain summaries of opportunities identified through second-level review for team feedback and education
- Compile trends and opportunity areas with Second Level Reviewers, CDI Leads, and CDI Educator
- Conduct one-to-one and group education based on review findings
- Review and recommend updates to second-level review criteria
- Perform targeted audits and participate in quality initiatives including HAC/PSI and US News/Mortality
- Collaborate to optimize query templates and identify workflow improvement opportunities
- Facilitate change management and support the CDI team through organizational changes
- Advance the CDI practice throughout the UH enterprise
- Participate in department-wide and enterprise-wide committees
- Perform other duties as assigned
- Comply with policies and standards governing the secure use of patient PHI
Requirements:
- Diploma in Nursing or Health Information Management, or Associate's Degree preferably in Health Information Management or Nursing, or Bachelor's Degree preferably in Health Information Management or Nursing, or Doctorate Degree in Medicine
- 3+ years CDI experience as a concurrent reviewer
- Extensive clinical knowledge and understanding of pathology/physiology, demonstrated by clinical experience in a hospital setting
- Strong critical thinking skills and ability to review medical records for undocumented information supported by clinical indicators or clinical clues
- Comprehension of Case Mix Index (CMI); ability to interpret, analyze, and evaluate data, provide rationale for trends/impacting factors, and develop strategies to correct/optimize CMI
- Knowledge of age-specific patient needs, disease processes, and related procedures
- Excellent written and verbal communication skills, including concise and effective communication with providers
- Assertive personality traits to facilitate ongoing physician communication
- Working knowledge of inpatient admission criteria
- Ability to work independently in a time-oriented environment and as part of a team, primarily in a virtual setting
- Maintain professional knowledge through relevant reading and webinars
- Earn and maintain Certification for Clinical Documentation Improvement
- Incorporate current literature, research, and best practices from ACDIS and AHIMA into daily practice
- Up-to-date clinical and coding experience and current working knowledge of pathology, pharmacology, surgical procedures, and related areas
- Detail-oriented and organized, with excellent time-management, analytical, and problem-solving abilities
- Client service, communication, presentation, and relationship-building skills
- RN Ohio and/or Multi State Compact License, or RHIA, or RHIT, required upon hire
- CCDS or CDIP required upon hire
- International medical doctor education and experience can meet qualifications in lieu of RN, RHIA, or RHIT
- Must safely and securely maintain Protected Health Information (PHI)
- Must comply with UH policies, procedures, Code of Conduct, and annual training requirements
Benefits:
- $5,000 Sign on Bonus
- Remote work
- Full-time regular employment
- Day shift
- No travel
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