A Brief Overview

Applies clinical expertise and knowledge of health care workflows in order to educate and train CDI Specialists in the essential duties of their role to improve the overall accuracy and comprehensiveness of medical record documentation, with focus on ensuring accurate reporting of quality outcomes. Educates CDI Specialists on the rules/regulations associated with coding and clinical documentation integrity. Trains newly hired CDI Specialists and provides ongoing coaching and education specific to daily CDI Specialist job functions. Ensures the work output of the Clinical Documentation Integrity staff is accurate and compliant. Collaborates with CDI leadership and Coding team to identify training opportunities and assist with education of CDI and Coding staff with regard to clinical documentation integrity and/or clinical and coding scenarios as needed.

What You Will Do

• Performs post-discharge, final coded, pre-bill reviews of targeted records identified for second-level review for opportunity 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.
• Subject matter expert that exhibits excellent skills in essential components of the CDI Specialist role.
• 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 CDI Educator to compile trends and areas of opportunity and conduct education both 1:1 and group education with the CDI team based on the findings.
• Periodically review the criteria established for cases triggering a second level review and recommend updates or modifications to the criteria to assist in identifying areas of opportunity.
• Is actively engaged in quality and process improvement efforts.
• Performs targeted audits as assigned in support of department initiatives.
• Participates in quality initiatives such as HAC/PSI and US News/Mortality.
• Collaborates with CDI Leadership, Leads and Educators to optimize query templates.
• Identifies and shares feedback regarding workflow improvement opportunities identified when completing the SLR process.
• Facilitates change and supports the CDI team through change management processes.
• Actively engages in advancing the CDI practice throughout the UH enterprise.
• Actively engages in department and/or enterprise-wide committee.

Additional Responsibilities

Performs other duties as assigned. Complies with all policies and standards. For specific duties and responsibilities, refer to documentation provided by the department during orientation. Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.

Education

Other Accredited Program: Diploma in Nursing or in Health Information Management (Required) or Associate's Degree preferably in Health Information Management or Nursing (Required) or Bachelor's Degree preferably in Health Information Management or Nursing (Required) or Doctorate Degree in Medicine (Required).

Work Experience

3+ years CDI experience as a concurrent reviewer (Required).

Knowledge, Skills, & Abilities

Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting (Required proficiency). Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues (Required proficiency). Demonstrates comprehension of Case Mix Index (CMI) and can interpret, analyze, evaluate data, provide rationale for trends/impacting factors and develop strategy for correcting/optimizing CMI (Required proficiency). Knowledge of age-specific patient needs and the elements of disease processes and related procedures (Required proficiency). Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers (Required proficiency). Assertive personality traits to facilitate ongoing physician communication (Required proficiency). Working knowledge of inpatient admission criteria. (Required proficiency). Ability to work independently in a time-oriented environment as well as working as part of a team, primarily in a virtual setting. (Required proficiency). Applies knowledge and expertise to daily job responsibilities. Maintains professional knowledge by reading and/or attending webinars that pertain to Clinical Documentation Improvement. (Required proficiency). Earns and maintains Certification for Clinical Documentation Improvement. (Required proficiency). Incorporates current literature, research and best practice ( ACDIS and AHIMA ) into daily practice. (Required proficiency). Up to-date clinical and coding experience, and current working knowledge of pathology, pharmacology, surgical procedures, etc. (Required proficiency). Detail-oriented and organized, have excellent time-management skills, and have good analytical and problem-solving ability. (Required proficiency). Notable client service, communication, presentation and relationship building skills. (Required proficiency).

Licenses and Certifications

Registered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire) or Registered Health Information Administration (RHIA) (Required Upon Hire) or Registered Health Information Technologist (RHIT) (Required Upon Hire) and Certified Clinical Documentation Specialist (CCDS) (Required Upon Hire) or Clinical Documentation Improvement Practitioner (CDIP) (Required Upon Hire). International medical doctor education and experience can meet qualifications in lieu of RN, RHIA or RHIT.

Physical Demands

Standing Occasionally, Walking Occasionally, Sitting Constantly, Lifting Rarely up to 20 lbs, Carrying Rarely up to 20 lbs, Pushing Rarely up to 20 lbs, Pulling Rarely up to 20 lbs, Climbing Rarely up to 20 lbs, Balancing Rarely, Stooping Rarely, Kneeling Rarely, Crouching Rarely, Crawling Rarely, Reaching Rarely, Handling Occasionally, Grasping Occasionally, Feeling Rarely, Talking Constantly, Hearing Constantly, Repetitive Motions Frequently, Eye/Hand/Foot Coordination Frequently.

Travel Requirements

10%25