Clinical Documentation Specialist - Full Time - Remote

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The Clinical Documentation Integrity Specialist (CDIS) performs clinically based health record reviews to facilitate and obtain appropriate provider documentation for clinical conditions and procedures to reflect severity of illness, accurate coding/DRG, expected risk of mortality, accuracy of patient outcomes, and complexity of patient care. Through compliant query processes and education, clarifies incomplete, conflicting, ambiguous, and/or missing provider documentation. The CDIS 1 works in collaboration with other CDI Specialists, coders, quality analysts, providers, and other members of the healthcare team to ensure accurate, high-quality clinical documentation to support UHealth initiatives. Adheres to departmental and organizational goals, objectives, standards of performance, policies and procedures, continually ensuring quality documentation and regulatory compliance.

•    Ensures accuracy, completeness, and quality of clinical information used for measuring and reporting physician and hospital outcomes.
•    Performs thorough and timely medical record reviews to identify potential gaps or opportunities to facilitate improved provider documentation. 
•    Follows designated case review workflows, including initial, continued stay, retrospective, and final CDI reviews. 
•    Ensure clinical documentation accurately reflects the level of care rendered, severity of illness, risk of mortality, and clinical validation (in compliance with government and other regulations).
•    Demonstrates proficiency with ICD-10-CM/PCS, APR DRG, and MS DRG by assigning accurate working DRGs based upon identification and selection of principal diagnosis, complications, co-existing or co-morbid conditions, POA indicators, and significant procedures.
•    Ensures documented conditions, clarifications, and coded diagnoses are clinically supported.
•    Follows up on queries per policy, including reviewing for continued appropriateness and updating pending queries as needed. 
•    Recognizes opportunities for documentation improvement using strong critical-thinking skills and sound judgment in decision making, keeping integrity and compliance at the forefront of considerations in addition to outcomes, reimbursement, and regulatory requirements. 
•    Facilitates high-quality documentation by utilizing queries that are effective, clear, concise, and compliant in accordance with latest AHIMA/ACDIS Query Practice Brief.  
•    Makes recommendation of possible refinement of principal diagnosis, secondary diagnoses, and/or procedures based on clinical data to facilitate appropriate DRG assignment.
•    Records review findings and other data elements timely and accurately into CDI Software and other data mechanisms to support data integrity for reporting.
•    Effectively and appropriately communicates and collaborates with providers, HIM/coding, quality, CDI, and other members of the healthcare team. 
•    Professionally interacts with providers to complete/resolve queries, provide education, and/or answer questions as needed. 
•    Escalates concerns with query responses, DRG reconciliation, notifications, etc. as appropriate or per departmental protocol. 
•    Performs timely reconciliation of working codeset/DRG compared to final codeset/DRG. Effectively communicate discrepancies with coding, including rationale and supporting evidence. Escalate as appropriate. 
•    Demonstrates willingness to learn and accepts feedback productively. 
•    Meets and maintains CDI quality and query compliance standards. 
•    Works independently; demonstrates effective time management and prioritization of tasks. Maintains productivity standards. 
•    Perform duties and conduct interpersonal relationships in a manner that promotes a team approach and collaborative work environment with physicians, CDI staff and coders.
•    Assumes responsibility for professional development through participation at workshops, conferences, and/or in-services and maintains appropriate records of participation.
•    Complies with and ensures adherence to HIPAA and Code of Conduct policies.
•    Other duties as assigned. 

Education:
Bachelor’s degree in Nursing, Health Information Manag