Concurrent Clinical Documentation Integrity (CDI) Specialist

TuftsMedicine; United States; À distance; USD 90 000 - 120 000; Plein temps

Résumé du poste

TuftsMedicine is seeking a Clinical Documentation Improvement Specialist to enhance the quality and integrity of the medical record. The role focuses on concurrent reviews of inpatient records to identify documentation opportunities, ensuring accuracy for severity of illness, mortality risk, diagnoses and services.

The incumbent will work in a high-volume production setting, provide guidance on documentation guidelines, and support coding, quality reporting, and compliance processes.

Qualifications

• Associate's degree in related healthcare field.
• One year of CDI experience in an acute care setting OR one year of acute care clinical experience relevant to CDI.
• Active, unrestricted RN license in MA or an NLC state; or applicable CDI certification.

Responsabilités

• Performs initial and concurrent reviews of electronic medical records to identify documentation opportunities.
• Evaluates medical records for completeness, consistency, precision and clarity.
• Identifies query opportunities for provider clarification and issues compliant, clinically supported queries.
• Exercise professional judgment in documentation and reporting according to policies.

Connaissances

CDI

Formation

Associate's degree in related healthcare field

RN license or equivalent CDI credentials (CCDS/CDIP/AHIMA/CCS/CIC)

Description du poste

Hours: 40 hours per week; Monday through Friday Location: Remote

Job Profile Summary

This role focuses on activities related to revenue cycle operations such as billing, collections, and payment processing. In addition, this role focuses on performing the following CDI related duties: Facilitates improvement in overall quality, completeness, and accuracy of medical record documentation, obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and coding staff to ensure that documentation reflects the level of service rendered to patients is complete and accurate, and serves as a resource to all team members on documentation guidelines, provides guidance and support as well as assisting in the education and training related to improving clinical documentation. A professional individual contributor role that may direct the work of other lower-level professionals or manage processes and programs. The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. An entry level role that applies broad theoretical job knowledge typically obtained through advanced education. May require the following proficiency: work is closely supervised, problems faced are not typically difficult or complex, and explains facts, policies and practices related to job area.

Job Overview

This position is responsible for enhancing the quality, accuracy, completeness, and integrity of clinical documentation within the medical record. This position ensures that documentation accurately reflects the patient's severity of illness, risk of mortality, diagnoses, procedures, and services provided. This position is responsible for conducting high volume, concurrent reviews of inpatient medical records to identify opportunities for improved clinical documentation accuracy, complements, and specificity. This position functions as a part of specialized production team designed to maximize review capacity through focused clinical review activities. Responsibilities in this role do not include physician query follow up, physician or provider outreach, query escalation, query reconciliation, CDI/Coding reconciliation as those functions will be performed by a dedicated team in those areas. Through comprehensive review of clinical records, this position identifies documentation opportunities, facilitates compliant clinical documentation clarification, and supports accurate coding, quality reporting, reimbursement, and regulatory compliance. This role is critical in ensuring the medical record accurately represents the patient's clinical condition while supporting organizational performance related to quality outcomes, case mix index, and reimbursement. This position requires the ability to consistently perform in a high production environment while maintaining exceptional quality standards. Incumbents are expected to meet established productivity goals and maintain a minim quality review score of 95% as measured through departmental quality audits and performance evaluations.

Job Description

Minimum Qualifications:

• Associate's degree in related healthcare field (ie, medical coding and billing programs, nursing programs, healthcare admin).
• One (1) year of Clinical Documentation Integrity (CDI) experience in an acute care setting; OR One (1) year of acute care clinical experience (ICU, Emergency Department, Critical Care, or Medical-Surgical specialties), case management, utilization review, or denials management.
• Active, unrestricted Registered Nurse (RN) license in Massachusetts; OR a Nurse Licensure Compact (NLC) state; OR AHIMA Certified Coding Specialist (CCS) credential; OR AAPC Certified Inpatient Coder (CIC).

Preferred Qualifications:

• Bachelor's degree in nursing (BSN) or Registered Health Information Administrator (RHIA) credential.
• Two (2) years of Clinical Documentation Integrity (CDI) experience in an acute care setting.
• Certified Clinical Documentation Specialist (CCDS) and/or Clinical Documentation Improvement Practitioner (CDIP) certification.

Duties and Responsibilities:

• Performs initial and subsequent concurrent reviews of electronic medical record to identify documentation opportunities, while consistently achieving established concurrent review volume goals and maintaining quality and accuracy standards.
• Evaluates the medical record for completeness, consistency, precision and clarity.
• Identifies query opportunities for provider clarification. Record and issue compliant, clinically supported queries in accordance with organizational policies and industry guidelines.
• Exercise professional judgment