Clinical Documentation Integrity Analyst (Remote)

University Hospitals Pain Management; Shaker Heights (OH); Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare institution in Ohio seeks a Clinical Documentation Improvement expert to enhance the accuracy of medical record documentation. The role involves performing audits, collaborating with teams, and engaging in quality initiatives. Ideal candidates possess a deep understanding of clinical workflows and a commitment to documentation integrity within healthcare settings.

Qualifications

• Expertise in clinical documentation integrity required.
• Experience in healthcare workflows is essential.
• Understanding of coding and compliance regulations beneficial.

Responsibilities

• Perform post-discharge reviews to ensure accurate medical record documentation.
• Coordinate with CDI and Coding teams to address documentation opportunities.
• Engage in quality improvement initiatives and participate in audits.

Skills

Clinical Documentation Integrity

Healthcare Workflows

Quality Improvement

Job description

Description

A Brief Overview

Is a subject matter expert and applies clinical expertise and knowledge of healthcare workflows to improve the overall accuracy and comprehensiveness of the medical record documentation. Collaborates with CDI leadership and Coding team to identify educational and workflow opportunities and assists with education of CDI and Coding staff regarding clinical documentation integrity and/or clinical and coding scenarios as needed.

Essential Duties:

• Performs post-discharge, final coded, pre-bill reviews of targeted records identified for second-level review to accurately capture patient acuity, severity of illness, risk of mortality, and DRG assignment in compliance with industry rules and regulations.

• Documents SLR findings within CDI application.

• If a documentation opportunity is identified, place physician query and follow up for response to ensure completeness and accuracy of the medical record.

• If coding opportunity is identified, coordinate with coder and/or Coding Leadership to review and address opportunity as applicable.

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

• Responds to CDS requests for concurrent chart reviews on challenging cases with recommendations and supporting rationale.

• Performs concurrent second level reviews based on defined criteria and shares feedback with CDI Specialist assigned to the encounter for action on opportunities identified.

• Maintains a summary of opportunities identified through second level review for feedback and education with the CDI team.

• Coordinates with other Second Level Reviewers, CDI Leads, and Educators to compile trends and conduct education based on findings.

• Reviews and recommends updates or modifications to the criteria for cases triggering a second level review.

• Is actively engaged in quality and process improvement efforts.

• Performs targeted audits in support of department initiatives.

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

• Collaborates to optimize query templates.

• Shares feedback on workflow improvement opportunities.

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

• Engages in advancing the CDI practice throughout the enterprise.

• Participates in department and enterprise-wide committees.