Clinical Documentation Integrity Specialist – Inpatient
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Job Description
Clinical Documentation Integrity Specialist reviewing inpatient medical records for accuracy and communication with healthcare staff. Collaborating with coding staff for correct documentation and education of medical professionals.
Responsibilities:
- Review inpatient medical records to ensure completeness and accuracy for severity of illness and risk of mortality.
- Ensure effective communication with healthcare staff to suggest additional documentation.
- Work closely with HIM coding staff to confirm discharge diagnoses and co-morbidities are accurately reflected.
- Conduct concurrent review of medical records and document findings on CDS worksheets.
- Identify principal and secondary diagnoses, procedures, and quality indicators.
- Clarify documentation as needed and facilitate accurate patient records.
- Use monitoring tools to track program progress and share findings.
- Educate staff on documentation improvement and facilitate compliance.
- Engage with healthcare team to improve clinical documentation processes.
Requirements:
- Associates Degree in Health Information Management or a related field from an accredited college or university.
- Certification in RHIT or RHIA along with CCDS or CDIP.
- For Nurses: Associate degree and 3 or more years of experience in an acute care setting.
- All other clinical disciplines: Associate degree in respective fields of study from an accredited college or university.
- Foreign medical graduate (MD) along with CDI certification of CCDS and/or CDIP in lieu of Kansas RN license is acceptable.
- 3 or more years of experience in Clinical Documentation, Case Management/Utilization Review, or Critical Care.
- Licensed Registered Nurse (LRN) - Single State or Multi-State - State Board of Nursing.
- Must have certification of CCDS or CDIP or foreign medical graduate (MD) with CDI certification.
Benefits:
- The health system is an equal employment opportunity employer.
- Provides reasonable accommodations to qualified individuals with disabilities.
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