Clinical Documentation Integrity Specialist II

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

📋 Description

• Ensures that documentation is precise and complete by conducting timely medical record reviews and determining code assignments, leveraging clinical and/or coding expertise to pinpoint opportunities for enhanced or clarified documentation that accurately reflects patient complexity and resource utilization.

• Conducts direct and prompt follow-ups with clinical providers to ensure that requested clarifications are obtained.

• Takes responsibility for expanding knowledge in CDI and coding by staying current on the latest research, technology, treatment methods, and more.

• Employs critical thinking and problem-solving techniques.

• Effectively utilizes and interprets professional association resource materials and regulatory agency guidelines to enhance personal skill sets, including Coding Clinics, AHIMA, and CMS guidelines.

• Identifies opportunities for queries that ensure record integrity.

• Demonstrates proficiency in crafting queries that are easily comprehensible to physicians.

• Ensures query writing is compliant with AHIMA standards as per practice briefs.

• Promptly escalates any lack of response to physician queries according to the query escalation policy.

• Collaborates effectively with the coding team.

• Shows proficiency in reviewing increasingly complex cases.

• Actively participates in educating physicians and other clinical providers on clinical documentation through various formats, including clinical rounding, service line-focused education sessions, and one-on-one case-specific feedback.

• Applies knowledge of healthcare workflows to work collaboratively with medical staff and other healthcare team members to enhance the accuracy and comprehensiveness of medical record documentation, with a focus on ensuring accurate reporting of quality outcomes.

⛳️ Requirements

• Education: Associate's Degree in a health-related field (Required) or other accredited program: Diploma in RN (Required), Bachelor's Degree in a health-related field (Preferred).

• Minimum of 2 years in a CDI Specialist role (Required).

• At least 3 years of clinical and/or ICD-10 coding experience, preferably in a large academic medical center (Required).

• Experience with clinical computer systems (Required).

• Must possess thorough, up-to-date clinical skills (i.e., current working knowledge of pathology, pharmacology, surgical procedures, etc.) (Required proficiency).

• Excellent written and verbal communication skills, including the ability to present (Required proficiency).

• Ability to work independently as well as part of a team in a fast-paced environment (Required proficiency).

• Detail-oriented with strong relationship-building skills (Required proficiency).

• Demonstrates extensive knowledge of disease pathophysiology (Required proficiency).

• Proven ability to use PCs, Microsoft Office Suite, and general office equipment (i.e., printers, copiers, FAX machines, etc.) (Required proficiency).

• Licenses and Certifications: Registered Nurse (RN), Ohio and/or Multi-State Compact License (Required Upon Hire) or Registered Health Information Administrator (RHIA) (Required) or Registered Health Information Technologist (RHIT) (Required) and Certified Clinical Documentation Specialist (CCDS) (Required) or Clinical Documentation Improvement Practitioner (CDIP) (Required).

🏝️ Benefits

• Complies with all policies and standards.