Clinical Documentation Improvement Officer-STMC-Coding and Clinical Documentation Improvement

Overview

The Clinical Documentation Improvement Officer collaborates with physicians, nursing staff, coding staff, quality department, and HIM staff to improve the quality and completeness of documentation of care provided and coded for coordination, abstraction, and submission of accurate data required by DOH and all payers. Facilitates concurrent modifications to clinical documentation to secure the appropriate reimbursement of clinical severity and services rendered to patients with a Diagnosis Related Group, following official coding guidelines as well as other methodologies published by DOH. Supports timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. Communicates with and educates hospital staff including but not limited to physicians, nursing, care management, allied health practitioners, coders, and other patient financial-service staff. Supports denial management team in providing the references to justify clinical documentation.

Responsibilities

• Review concurrent medical records for compliance including completeness and accuracy for the severity of illness (SOI), risk of mortality (ROM), patient safety indicators (PSI), hospital-acquired conditions (HACs), and quality of the documentation.
• Complete accurate and timely record reviews to ensure the integrity of documentation compliance.
• Identify opportunities for documentation improvement using strong critical-thinking skills. Use critical thinking and sound judgment in decision making balancing reimbursement considerations with regulatory compliance.
• Identify documentation gaps and obtain the documentation updated by the care provider by developing queries in compliance with ethical documentation standards with clinical validation and references from the documentation.
• Work closely with physician champions, clinical coders, case managers, nursing staff, and quality departments in resolving queries and updating the documentation.
• Concurrently update the CDI tool with findings and remarks based on the documentation review to validate and monitor the CDI metrics.
• Strategically educate members of the patient-care team regarding documentation regulations and guidelines, including attending physicians, allied health practitioners, nursing, and care management.
• Effectively and appropriately communicate with physicians and other healthcare providers to ensure appropriate, accurate, and complete clinical documentation. Communicate with HIM staff and collaborate to resolve discrepancies with DRG assignments and other coding issues.
• Complete well-timed follow-up case reviews on all concurrent cases with priority given to resolution of those with clinical documentation clarifications.
• Participate in meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified.
• Use the available systems and applications to generate the reports and provide the statistics to the stakeholders in a periodic manner.
• Other duties as may be assigned.

Qualifications

• Required: One to two years of real-time experience in CDI.
• Desired: Four to five years of inpatient coding; good knowledge in IR-DRG, ICD-10-CM, and CPT Coding guidelines; experience with statistical analysis/data analysis; experience with Excel/Power BI/Tableau; knowledge of SQL/Python is a plus.

Details

• Seniority level: Entry level
• Employment type: Full-time
• Job function: Administrative
• Industries: Hospitals and Health Care