Clinical Documentation Integrity Analyst

This is a fully remote position, open to applicants in Ohio.

📋 Description

• Utilizes clinical expertise and understanding of healthcare workflows to educate and train CDI Specialists on their key responsibilities, aiming to enhance the accuracy and comprehensiveness of medical record documentation, with a focus on precise reporting of quality outcomes.

• Provides education to CDI Specialists regarding the rules and regulations linked to coding and clinical documentation integrity.

• Trains newly onboarded CDI Specialists and offers continuous coaching and education tailored to the daily functions of a CDI Specialist.

• Ensures that the output from the Clinical Documentation Integrity staff is both accurate and compliant.

• Collaborates with CDI leadership and the Coding team to pinpoint training opportunities and support the education of CDI and Coding staff concerning clinical documentation integrity and relevant clinical and coding scenarios as necessary.

• Conducts post-discharge, final coded, pre-bill reviews of selected records flagged for second-level review to accurately capture patient acuity, illness severity, mortality risk, and DRG assignment in accordance with industry regulations.

• Records SLR findings within the CDI application.

• If a documentation opportunity is found, initiates a physician query and follows up for a response to ensure the completeness and accuracy of the medical record.

• If a coding opportunity is identified, coordinates with the coder and/or Coding Leadership to review and address the opportunity as appropriate.

• Acts as a role model and resource for CDI team members.

• Serves as a subject matter expert, demonstrating excellent skills in the essential functions of the CDI Specialist role.

• Responds to CDS requests for concurrent chart reviews on complex cases, providing recommendations and supporting rationale.

• Conducts concurrent second-level reviews based on established criteria and shares feedback with the CDI Specialist assigned to the encounter to address identified opportunities.

• Maintains a summary of opportunities recognized during second-level reviews for feedback and education with the CDI team.

• Collaborates with other Second Level Reviewers, CDI Leads, and the CDI Educator to compile trends and areas for improvement, conducting both one-on-one and group education with the CDI team based on findings.

• Regularly reviews the criteria established for cases that warrant second-level reviews and suggests updates or modifications to assist in identifying areas for improvement.

• Actively participates in quality and process improvement initiatives.

• Conducts targeted audits as assigned to support departmental initiatives.

• Engages in quality initiatives such as HAC/PSI and US News/Mortality.

• Collaborates with CDI Leadership, Leads, and Educators to enhance query templates.

• Identifies and shares insights regarding workflow improvement opportunities discovered during the SLR process.

• Facilitates change and supports the CDI team through change management processes.

• Actively works to advance the CDI practice across the UH enterprise.

• Participates in department and/or enterprise-wide committees.

• Performs additional duties as assigned. Adheres to all policies and standards. For specific responsibilities, please refer to the documentation provided by the department during orientation.

⛳️ Requirements

• Diploma in Nursing or Health Information Management (Required)

• Associate's Degree, preferably in Health Information Management or Nursing (Required)

• Bachelor's Degree, preferably in Health Information Management or Nursing (Required)

• Doctorate Degree in Medicine (Required)

• 3+ years of CDI experience as a concurrent reviewer (Required)

• Extensive clinical knowledge and comprehension of pathology/physiology, best demonstrated through clinical experience in a hospital setting (Required proficiency)

• Strong critical thinking skills and the ability to review medical records to identify undocumented information supported by clinical indicators or clues (Required proficiency)

• Demonstrates understanding of Case Mix Index (CMI) and can interpret, analyze, and evaluate data, providing reasoning for trends and impacting factors while developing strategies for correcting or optimizing CMI (Required proficiency)

• Knowledge of age-specific patient needs and elements of disease processes and related procedures (Required proficiency)

• Excellent written and verbal communication skills; ability to write concisely and effectively when engaging with providers (Required proficiency)

• Assertive personality traits to facilitate ongoing communication with physicians (Required proficiency)

• Working knowledge of inpatient admission criteria (Required proficiency)

• Ability to work independently in a time-sensitive environment while also functioning as part of a team, primarily in a virtual setting (Required proficiency)

• Applies knowledge and expertise to daily responsibilities; maintains professional knowledge by reading and/or attending webinars related to Clinical Documentation Improvement (Required proficiency)

• Obtains and maintains Certification for Clinical Documentation Improvement (Required proficiency)

• Incorporates current literature, research, and best practices (ACDIS and AHIMA) into daily work (Required proficiency)

• Up-to-date clinical and coding experience, along with current knowledge of pathology, pharmacology, surgical procedures, etc. (Required proficiency)

• Detail-oriented and organized, possessing excellent time-management skills, as well as strong analytical and problem-solving abilities (Required proficiency)

• Notable client service, communication, presentation, and relationship-building skills (Required proficiency)

🏝️ Benefits

• $5,000 Sign on Bonus