Clinical Documentation Integrity Specialist I, FT, Days, Remote

Prisma Health; United States; Remote; USD 70,000 - 100,000; Full time

Job summary

Prisma Health in the United States is seeking a Clinical Documentation Integrity (CDI) professional to review medical records, identify opportunities to accurately reflect severity of illness, risk of mortality, length of stay, and hospital quality metrics, and collaborate with coding and clinical teams.

The role emphasizes concurrent reviews, provider queries, and reconciliation to ensure accurate coding; requires RHIA/RHIT/CCS/CIC or RN licensure, strong communication, and knowledge of

Qualifications

• Associate degree required in nursing, health information management, or related field.
• Two years of adult medical/surgical/critical care/ER/PACU nursing coding or related experience.
• MD/DO/PA/NP may substitute education and experience.

Responsibilities

• Conduct concurrent medical record reviews for clarity, completeness and accuracy.
• Use query process to reflect severity of illness, ROM, comorbid conditions and POA.
• Complete reconciliation to ensure accurate coding reflecting LOS, diagnosis and POA status.
• Develop and maintain relationships with providers and health care teams for education.
• Stay current with coding guideline changes and compliant query policies.
• Serve as a resource for coworkers, providers and other departments.
• Assign a working DRG for discharge planning and CDI use.
• Perform other duties as assigned.

Skills

Communication skills

Computer skills

IPPS ICD10 Coding knowledge

Education

Associate degree in Nursing, Health Information Management, or related field

Job description

Inspire health. Serve with compassion. Be the difference.

Job Summary

Job Profile Summary

Reviews medical records to identify documentation opportunities to accurately represent the severity of illness, risk of mortality, length of stay, intensity of service, and hospital quality metrics. Reviews medical records, submits provider queries, and reconciles discharged records. Collaborates with Coding and other departments to facilitate the highest level of accuracy, quality, and completeness of provider documentation as well as accurate code assignment.

Job Description

Essential Functions

• All team members are expected to be knowledgeable and compliant with Prisma Health's purpose: Inspire health.Serve with compassion.Be the difference.
• Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency and accuracy of clinical documentation.
• Employs the query process as needed to provide accurate documentation reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.
• Completes the reconciliation process to ensure accurate coding reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.
• Develops and maintains supportive, collaborative relationships with providers and health care team members to include education and follow up.
• Stay current with coding guideline changes, changes in treatment modalities, clinical disease indicators, and compliant query policies.
• Serves as a resource for co-workers, providers, and other support departments (coding, case management, quality, nutrition, etc.)
• Assigns a working DRG for health care team discharge planning and CDI use.
• Performs other duties as assigned

Supervisory/Management Responsibilities

• This is a non-management job that will report to a supervisor, manager, director or executive.

Minimum Requirements

• Education - Associate degree in Nursing, Health Information Management, or related field of study
• Experience - Two (2) years -adult medical/surgical/critical care/ER/PACU nursing coding or related experience

In Lieu Of

• In lieu of the education and experience requirements noted above, the following combination of education, training and/or experience may be considered an equivalent substitution: MD/DO/PA/NP

Required Certifications, Registrations, Licenses

• RHIA/RHIT/CCS/CIC/or Licensure in related field of study/ Holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working.

Knowledge, Skills and Abilities

• Computer skills
• Communication skills with ability to interact with providers.
• General knowledge of IPPS, ICD10 Coding, MS-DRG/APR-DRG and HCPCS coding systems preferred

Work Shift

Day (United States of America)

Location

Corporate - Columbia - Taylor at Marion

Facility

Corporate

Department

Clinical Documentation Integrity

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