Clinical Documentation Integrity Specialist VI

Job Summary:

Performs a second-level review medical/health records to promote the accuracy and completeness of clinical documentation and acts as an expert resource for assigning medical codes and diagnostics-related groups (DRGs) to facilitate the accurate capture of diagnoses. Assists in enhancing the clinical documentation improvement/integrity (CDI) program by collaborating with leadership to conduct data and root cause analyses to identify trends and improvement opportunities in clinical review and documentation processes. Supports regulatory compliance by conducting audits, reviewing clinical documentation, and addressing and/or reporting cases of non-compliance in line with coding guidelines and federal regulations. Develops and leads staff trainings and education on clinical documentation improvement (e.g., medical review and coding, quality standards, documentation requirements for diagnosis capture).

Essential Responsibilities:

• Promotes learning in others by communicating information and providing advice to drive projects forward; builds collaborative, cross-functional relationships. Solicits and acts on performance feedback; provides actionable feedback to others, including upward feedback to leadership; influences, mentors, and coaches team members. Practices self-leadership; creates, evaluates, and responds to the strengths and weaknesses of self and unit or team members. Leads the adaptation to competing demands and new responsibilities; adapts to and learns from change, challenges, and feedback. Fosters open dialogue amongst team members.
• Drives the execution of multiple work streams by identifying member and operational needs; translates business strategy into actionable business requirements; develops and updates new procedures and policies. Gains cross-functional support for objectives and priorities; determines and carries out processes and methodologies; solves highly complex issues; escalates and resolves issues as appropriate; sets standards and measures progress. Develops work plans to meet business priorities and deadlines; coordinates, obtains and distributes resources. Removes obstacles that impact performance; guides performance and develops contingency plans accordingly; influences the completion of project tasks by others.
• Provides expert consultation on clinical documentation reviews by: performing a second-level review of medical/health records to promote the accuracy and completeness of clinical documentation and serving as a resource for complex reviews; acting as a region-wide educator and/or performing quality assurance reviews of complex cases reviewed by other clinical documentation improvement/integrity (CDI) reviewers and providing expert consultation to other CDI reviewers; serving as an expert resource for applying and documenting medical codes to facilitate the accurate capture of diagnoses; offering expertise to medical providers to identify the presence of medical conditions that impact severity of illness (SOI) and risk of mortality (ROM) indicators; and creating and monitoring high importance and/or complex documentation clarification queries and facilitating the efficient resolution of all open queries.
• Leads processes to improve clinical documentation and/or evaluate performance by: providing mentorship on handling complex documentation issues, contradictions, or omissions; collaborating with leadership to conduct data and root cause analyses to identify trends and improvement opportunities in clinical review and documentation processes; and identifying opportunities for improvement related to clinical documentation, and collaborating with leaders to implement documentation improvement initiatives.
• Contributes to staff training and education by: identifying opportunities, developing and/or leading trainings on clinical documentation improvement/integrity (e.g., medical review and coding, quality standards, documentation requirements for diagnosis capture); and collaborating with leadership on the region-wide development and implementation of programs for clinical documentation education/training.
• Facilitates regulatory compliance by: identifying and resolving challenges to completing clinical documentation work in line with regulatory requirements; performing the clinical documentation audit process to facilitate compliance with coding guidelines and federal regulations; addressing and/or reporting cases of non-compliance; and independently identifying needs and opportunities to maintain up-to-date knowledge of relevant regulations and mentoring team members on regulatory changes.