Clinical Documentation Integrity Specialist III

Uofmhealth; Ann Arbor (MI); Hybrid; USD 60,000 - 90,000; Full time

Job summary

An innovative healthcare organization seeks a Clinical Documentation Integrity Specialist III to enhance the quality of clinical documentation. This fully remote role involves leading complex case reviews, collaborating with clinical staff, and developing educational plans to ensure comprehensive documentation. The ideal candidate will possess a strong background in clinical documentation improvement, data analysis, and effective communication skills. Join this forward-thinking team and play a vital role in supporting healthcare initiatives while enjoying the flexibility of remote work with occasional onsite requirements.

Qualifications

• Bachelor's degree or equivalent in health information technology.
• 3-5 years of CDI experience with coded data.

Responsibilities

• Perform high-level case reviews to identify documentation gaps.
• Collaborate with healthcare team members to ensure accurate documentation.

Skills

Clinical Documentation Improvement

Communication Skills

Leadership

Data Analysis

Education

Bachelor's degree in Health Information Technology

CCDS or CDIP credential

Tools

CDI Software

Healthcare Quality Metrics

Job description

Clinical Documentation Integrity Specialist III

Join to apply for the Clinical Documentation Integrity Specialist III role at Michigan Medicine.

Job Summary

The Clinical Documentation Integrity Specialist III (CDIS III) role is entirely remote, encompassing Team Lead responsibilities and second-level review duties. These roles are crucial in enhancing the quality and completeness of provider-based clinical documentation within inpatient medical records.

The CDIS III performs high-level, complex, secondary case reviews to facilitate and obtain appropriate provider documentation for clinical conditions or procedures, reflecting severity of illness, expected risk of mortality, accuracy of patient outcomes, PSI90/HAC reviews, clinical denials, and appeals. Serves as a key resource for CDI/Coding/Quality, collaborating with healthcare team members to ensure accurate, high-quality documentation supporting Michigan Medicine initiatives.

Responsibilities include facilitating accurate representation of a patient's clinical status affecting POA, SOI, ROM scores, hospital reimbursement, and services provided. The role involves collaborating with physicians and clinical staff to ensure comprehensive documentation, developing educational plans for providers, and highlighting the impact of documentation on clinical scores and LOS.

Responsibilities

• Perform high-level, complex case reviews to identify documentation gaps.
• Ensure documentation reflects care level, severity, risk, and validation in compliance with regulations.
• Apply knowledge of CMS star ratings, Vizient, and US News risk adjustment systems.
• Conduct quality reviews on mortality, HAC, and safety metrics.
• Identify trends and recommend documentation improvements.
• Record findings accurately in CDI software and other systems.
• Communicate effectively with providers and team members.
• Assist with CDI case reviews, audits, and education.
• Participate in meetings, provide feedback, and develop educational materials.
• Utilize CDI software for DRG, SOI, ROM, Risk, and POA determinations.
• Evaluate clinical documentation for improvement opportunities and clarify with providers.
• Initiate communication via formal query process.
• Prepare documentation examples and presentations for education.
• Develop and conduct ongoing staff education.
• Follow relevant policies and standards.
• Participate in audits, denials, and appeals processes.
• Perform other duties as needed to maintain departmental efficiency.

Minimum Qualifications

• Bachelor's degree or equivalent in health information technology, registered with AHIMA as RHIT or RHIA, or RN/Nurse Practitioner/PA/MD certification.
• 3-5 years of CDI experience with coded data.
• Two years in a CDIS role at Michigan Medicine.
• Experience analyzing Vizient risk data and AHRQ measures.
• CCDS or CDIP credential.
• Proficiency in productivity, communication, and leadership.
• Adherence to remote work policies.

Work Mode

Mostly remote work with occasional onsite requirements as needed.

Background Screening

Includes background check and pre-employment drug testing per policy.

Application Process

Minimum posting of 7 days; review may begin earlier. Position can be filled anytime after posting ends.

Equal Opportunity

Michigan Medicine is an equal employment opportunity employer.