Clinical Documentation Integrity Specialist

📋 Description

• This role involves the concurrent review of inpatient medical records to identify opportunities for enhancing the quality of physician documentation.

• It facilitates improvements in clinical documentation through real-time interactions with physicians (both face-to-face and electronically) and other healthcare team members.

• The objective of this role is to ensure a complete medical record, which supports accurate and timely coding.

• Communicates with physicians, case managers, coders, and other healthcare professionals to ensure comprehensive medical record documentation that accurately reflects clinical treatment, decisions, and diagnoses for inpatients.

• Utilizes the hospital's designated clinical documentation system to pinpoint opportunities for enhancing physician and hospital outcomes.

• Provides or coordinates education for all internal stakeholders regarding compliance, coding, and clinical documentation issues, and serves as a consultant to coders when additional information or documentation is required for assigning the correct DRG.

• Responsible for the ongoing evaluation of documentation by the medical staff and healthcare team in line with the hospital’s designated clinical documentation system.

• Collects and analyzes information relevant to documentation findings and outcomes.

• Contributes to a positive work environment and undertakes additional duties as assigned to support the overall goals of the organization.

• Develops educational strategies for physicians to promote complete and accurate clinical documentation while addressing negative trends.

• Identifies patterns, trends, variances, and opportunities to enhance documentation review and processes.

• Researches literature and keeps updated on CMS rules and regulations, incorporating changes into daily practices for overall documentation improvement.

• Assists in the development and communication of performance measures to the medical staff and other departments, and prepares physician-specific data reports.

• Engages with key physicians to discuss outcome information (including relevant physician profile data) related to documentation clarity, completeness, and accurate DRG designation.

• Coaches physicians to enhance their documentation to more accurately reflect the intensity of services and severity of illness.

• Records conference outcomes and results.

• Participates in various hospital service line meetings, reviewing outcome data, and educating physicians on service line-specific improvement opportunities.

• Adheres to HIPAA regulations and the Code of Conduct policies.

• Assists with special projects as required.

• Demonstrates competency in individual performance and development across the following areas: Customer Service, Job Skills, Resource Management, Teamwork, and Innovation.

• The directors will determine the percentage weight distribution for each competency category.

• Ensures safe care for patients, staff, and visitors; complies with all Memorial Hermann policies, procedures, and standards within budgetary constraints, including time management, supply management, productivity, and service quality.

⛳️ Requirements

• Preferably an RN candidate with experience in Clinical Documentation.

• Must hold an RN degree with either a BSN or MSN.

• A minimum of 5 years of recent RN bedside experience in an acute hospital setting is required.

• Pediatrics, NICU, Critical Care, and/or ICU nursing experience is necessary for consideration.

• Five (5) years of inpatient, acute care experience at the bedside in a nursing unit is required; ICU experience is preferred.

• Excellent observation skills, analytical thinking, problem-solving abilities, as well as strong verbal and written communication skills are essential.

• A working knowledge of various areas of adult medicine is required.

• Capable of assessing, evaluating, and teaching.

• Proficient in organization and planning.

• Proficiency in computer use, including database and spreadsheet analysis, presentation software, word processing, and Internet searching.

• Willingness to seek and adapt to change.

• Demonstrates adaptability, flexibility, self-motivation, and the ability to work independently.

• Knowledge of federal, state, and private payer regulations is preferred.

• Professional demeanor, team-oriented, and effective communication skills are crucial.

• Strong interpersonal skills combined with a positive attitude are essential.

🏝️ Benefits

• Regular, meaningful interaction with other personnel within and outside Memorial Hermann; contact may occur in person, via telephone, or through correspondence.