Clinical Documentation Integrity Specialist

Position Objective

Reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. Works collaboratively with physicians, other healthcare professionals and coding staff to ensure that clinical information in the medical record is present and accurate so that the appropriate utilization, clinical severity, outcomes and quality is captured for the level of service rendered to all patients, as well as ensuring compliant reimbursement of patient care services. Remains aware of the continual changes in Federal and State regulations for prospective payment, keeps informed of changes in treatment modes and new procedures, and performs coding when physician documentation is vague or missing.

 Essential Functions

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.  Reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters;
2.  Translates diagnostic phrases utilized by healthcare providers into coded form;
3. Interacts with the healthcare provider to ensure that the terms have been translated correctly;
4. Assigns the appropriate DRG after concurrent review of the medical record;
5. Works as a part of a coding team;
6. Maintains awareness of the continual changes in Federal and State regulations for prospective payment;
7. Keeps informed of changes in treatment modes and new procedures, and to perform coding when physician documentation.

 Required Education

• At least one of the following: Physician, Registered Nurse, Nurse Practitioner, Physician Assistant, and or a Professional Coder.

Required Experience

• Minimum of three-five years of health care experience required
• Strong medical surgical background is preferred.
•  Experience with utilization management, coding/DRG, billing, auditing and various health care payers is also preferred;
• Clinician preferred and or CDIP/CCDS credential.

Knowledge, Skills, Abilities:

•  Working knowledge of basic computer programs and Microsoft Office Suite;
• Typing; Ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.;
• Inpatient coding skills;
• High level of interpersonal and communication skills necessary to establish rapport with physicians and other healthcare providers;
• Chart review experience; Electronic Medical Record and CDI Software experience is preferred; Regulatory background and DRG reimbursement knowledge is preferred

Working Conditions, Equipment, Physical Demands:

Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.

There is reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.

The above is intended to describe the general content of and requirements for the performance of this job. It is not to be construed as an exhaustive statement of duties, responsibilities or requirements.