Ensures that documentation supports accurate complete and consistent unambiguous clinical documentation. Utilizes clinical expertise to support appropriate reflection of the patient’s risk of mortality and severity of illness. Develops compliant physician queries guided by the American Health Information Management Associations (AHIMA) Ethical Standards for Clinical Documentation Improvement Professionals the ACDIS/AHIMA Query practice brief and state federal and other appropriate regulatory guidance. Evaluates the medical records for case specific review including mortalities complications quality of care and other needs identified requiring review and/or second level review. Reviews and analyzes inpatient record for compliant documentation. Provides education to all levels of clinical staff. Closely collaborates with coding professionals to ensure appropriate ICD-10 and DRG assignment. Maintains certification and credentials applicable to the Clinical Documentation Integrity Specialist role. Monitors clinical case data to identify areas of improvement.
Primary Duties and Responsibilities
- Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
- Demonstrates a cooperative collaborative and team-oriented approach with CDI team coders nursing staff medical staff and all other ancillary departments. Communicates effectively to ensure a coordinated standardized and effective approach with clinicians.
- Demonstrates the appropriate utilization of paper and electronic CDI chart review resources to foster transition of cases within the CDI team. Ensures the CDI work sheet includes precise clinical details appropriate data entry into software and complete and updated code set to support physician queries and support case review decisions.
- Develops written and verbal CDI physician queries in compliance with AHIMA/ACDIS query practice brief and other appropriate regulatory body requirements.
- Identifies opportunities for education based upon query topics or other identified need and provides on-going education to physicians clinicians and other stakeholders about the need for accurate complete and consistent documentation in the medical record.
- Inputs daily review data in a timely manner including number of cases reviewed number of queries placed working MS-DRG or APR-DRG secondary diagnoses procedures and determination of MS-DRG or APR-DRG.
- Maintains continuing education and credentials for clinical documentation integrity specialist job classification.
- Meets the organizations CDS performance standards including but not limited to productivity (initial reviews and follow up reviews) query rate and documentation clarification rate.
- Participates in identifying areas of opportunity to improve the success or mitigate barriers in the CDI program and collaborates with the CDI Director to develop action plans to address issues.
- Participates in meetings and on committees and represents the department and hospital in community outreach efforts as required.
- Participates in the collection analysis and trending of CDI data to identify opportunities for improvement and to develop education for medical and hospital staff.
- May be asked to participate in the retrospective review of principal and secondary diagnoses to ensure the accuracy of diagnostic and procedural data.
- Performs initial and follow-up CDI chart reviews in accordance to the Hospitals CDI Policies and Procedures.
- Performs quality chart reviews in accordance to the Hospital CDI policies and procedures. Ability to recognize and research clinically complex conditions and associated global exclusions. Utilizes coding and CDI resources in an effort to apply the correct coding guidelines and clinical information to the review of the patients record.
- Performs other duties as assigned.
- Provides input in the development of power plans best practice guidelines and power notes within the hospital EMR systems to facilitate adherence to best practices and regulatory requirements.
- Reviews the medical record and evaluates the documentation to assign the Principal Diagnosis pertinent secondary diagnoses and procedures for accurate MS-DRG or APR-DRG assignment/Severity of Illness and Risk of Mortality.
Minimal Qualifications
Education
- Associate’s degree in Nursing required or
- Bachelor’s degree in Nursing preferred or
- Master’s degree Nursing or other clinically focused field of study such as Advanced Practice Nursing Physician Assistant preferred or
- Doctoral degree Foreign Medical Graduate preferred
Experience
- 3-4 years nursing Experience in acute care setting required and
- Experience in ICD-10 coding review and DRG reimbursements systems required
Licenses and Certifications
- Cert Document Improvement Practitioner – CDIP within 2 years required or
- CCDS – Certified Clinical Documentation Specialist within 2 years required and
- CCS-Certified Coding Specialist preferred
Knowledge Skills and Abilities
- Proficient in Microsoft Office applications (Word Excel PowerPoint).
- Excellent interpersonal skills including verbal and written communication.
- Ability to collect and analyze data related to the CDI program.
- Proficient in reviewing medical records and understanding pertinent clinical information.
- Ability to demonstrate critical-thinking skills.
This position has a hiring range of
USD $89,065.00 – USD $162,801.00 /Yr.
In addition to your salary, MedStar Health offers a comprehensive healthcare package (including medical, dental and vision subject to eligibility requirements) and other benefits. The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by MedStar Health. MedStar Health is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
The hiring range is the range MedStar Health, in good faith, believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on work experience, education and/or skill level, etc. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in MedStar Health’s sole discretion unless and until paid and may be modified at MedStar Health’s sole discretion, consistent with the law.
Why MedStar Health?
At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through:
- Strong emphasis on teamwork—our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.
- Strategic focus on equity, inclusion, & diversity—we are committed to equity for all people and communities. We continue to build a diverse and inclusive workplace where people feel a sense of belonging and the ability to contribute to equitable care delivery and improved community health outcomes at all levels of the organization.
- Comprehensive total rewards package—including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.
- More career opportunities closer to home—as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.
About MedStar Health
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C. region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It’s how we treat people.
MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations. MedStar Health entities that are federal government contractors are Equal Opportunity and Affirmative Action employers. MedStar Health makes all decisions regarding employment, including for example, hiring, transfer, promotion, compensation, benefit eligibility, discipline, and discharge without regard to any protected status, including race, color, creed, religion, national origin, citizenship status, sex, age, disability, veteran status, marital status, sexual orientation, gender identity or expression, political affiliations, or any other characteristic protected by federal, state or local EO laws. If you receive an offer of employment, it is MedStar Health’s policy to hire its employees on an at-will basis, which means you or MedStar Health may terminate this relationship at any time, for any reason.
