Clinical Documentation Integrity Analyst

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

📋 Description

• Educate and train CDI Specialists on their essential responsibilities, coding regulations, and clinical documentation integrity.

• Provide training for newly hired CDI Specialists and offer ongoing coaching and educational support.

• Ensure that the work of Clinical Documentation Integrity staff is precise and in compliance with regulations.

• Collaborate with CDI leadership and Coding teams to identify training and educational opportunities.

• Conduct post-discharge, final-coded, pre-bill second-level reviews to capture patient acuity, illness severity, mortality risk, and DRG assignment.

• Record findings from second-level reviews in the CDI application.

• Initiate physician queries and follow up on responses when documentation opportunities arise.

• Coordinate with coders and Coding Leadership regarding coding opportunities.

• Act as a role model, subject matter expert, and resource for members of the CDI team.

• Address CDS requests for concurrent chart reviews on complex cases.

• Conduct concurrent second-level reviews and provide feedback to assigned CDI Specialists.

• Maintain summaries of opportunities for feedback and education for the CDI team.

• Analyze trends and opportunities with reviewers, CDI Leads, and the CDI Educator; provide individual and group education.

• Review and propose updates to the criteria for second-level reviews.

• Conduct targeted audits and engage in quality initiatives, including HAC/PSI and US News/Mortality.

• Collaborate on the optimization of query templates.

• Identify opportunities for workflow improvements and support change management initiatives.

• Promote CDI practices throughout the UH enterprise and participate in relevant committees.

• Perform additional duties as assigned and adhere to policies, standards, and PHI regulations.

⛳️ Requirements

• Diploma in Nursing or Health Information Management, or an Associate's/Bachelor's degree preferably in Health Information Management or Nursing, or a Doctorate Degree in Medicine.

• A minimum of 3 years of CDI experience as a concurrent reviewer.

• Comprehensive clinical knowledge and understanding of pathology/physiology, evidenced by clinical experience in a hospital environment.

• Strong critical thinking abilities and the capacity to review medical records for undocumented information supported by clinical indicators or clues.

• Understanding of Case Mix Index (CMI); ability to interpret, analyze, and evaluate data to develop strategies for optimizing CMI.

• Knowledge of age-specific patient needs, disease processes, and related procedures.

• Exceptional written and verbal communication skills, including the ability to communicate effectively and concisely with providers.

• Assertive personality traits to enhance ongoing communication with physicians.

• Familiarity with inpatient admission criteria.

• Ability to work autonomously in a time-sensitive environment and as part of a team, primarily in a virtual setting.

• Maintains professional knowledge through relevant literature and webinars.

• Obtains and retains Certification for Clinical Documentation Improvement.

• Integrates current literature, research, and best practices from ACDIS and AHIMA.

• Up-to-date knowledge in clinical and coding practices, including pathology, pharmacology, and surgical procedures.

• Detail-oriented, organized, and possesses strong time-management, analytical, and problem-solving skills.

• Excellent client service, communication, presentation, and relationship-building abilities.

• Required upon hire: RN Ohio and/or Multi-State Compact license, or RHIA, or RHIT.

• Required upon hire: CCDS or CDIP certification.

• Education and experience as an international medical doctor may qualify in place of RN, RHIA, or RHIT.

🏝️ Benefits

• $5,000 sign-on bonus.