Documentation Integrity Specialist V, Clinical Licensure

Job Summary

Reviews a large caseload of medical/health records to promote the accuracy and completeness of clinical documentation and assigns medical codes and diagnostics-related groups (DRGs) to facilitate the accurate capture of diagnoses, and provides guidance on the use of appropriate codes as needed.

Assists in enhancing the clinical documentation improvement/integrity (CDI) program by reviewing and integrating processes to improve the accuracy and completeness of clinical documentation and documentation issue resolution. Ensures regulatory compliance by aiding audits, reviewing clinical documentation, and reporting cases of non-compliance in line with coding guidelines and federal regulations.

Leads staff trainings and education on clinical documentation improvement (e.g., medical review and coding, quality standards, documentation requirements for diagnosis capture).

Essential Responsibilities

• Promotes learning in others by communicating information and providing advice to drive projects forward; builds relationships with cross-functional stakeholders. Listens, responds to, seeks, and addresses performance feedback; provides actionable feedback to others, including upward feedback to leadership and mentors junior team members. Practices self-leadership; creates and executes plans to capitalize on strengths and improve opportunity areas; influences team members within assigned team or unit. Adapts to competing demands and new responsibilities; adapts to and learns from change, challenges, and feedback. Models team collaboration within and across teams.
• Conducts or oversees business-specific projects by applying deep expertise in subject area; promotes adherence to all procedures and policies. Partners internally and externally to make effective business decisions; determines and carries out processes and methodologies; solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Develops work plans to meet business priorities and deadlines; coordinates and delegates resources to accomplish organizational goals. Recognizes and capitalizes on improvement opportunities; evaluates recommendations made; influences the completion of project tasks by others.
• Performs clinical documentation reviews by: reviewing a large caseload of medical/health records to promote the accuracy and completeness of clinical documentation and capturing results of review; summarizing results of a large caseload of medical record reviews and guiding medical providers to rectify identified omissions or contradictions in medical records; assigning medical codes and diagnostics-related groups (DRGs) to facilitate the accurate capture of diagnoses and providing guidance on use of appropriate codes as needed; working with medical providers to identify the presence of medical conditions that impact severity of illness (SOI) and risk of mortality (ROM) indicators; and creating and monitoring documentation clarification queries to facilitate efficient resolution of open queries.
• Conducts processes to improve clinical documentation by: conducting reviews of the clinical documentation improvement/integrity (CDI) program to ensure processes are effectively improving the accuracy and completeness of clinical documentation and documentation issue resolution; identifying improvement opportunities in clinical review and documentation processes; and recommending opportunities for improvement related to clinical documentation and promoting the implementation of documentation improvement initiatives.
• Leads staff training and education by: leading and/or assisting trainings on CDI (e.g., medical review and coding, quality standards, documentation requirements for diagnosis capture); and identifying opportunities and collaborating with leadership to develop programs for clinical documentation education/training.
• Ensures regulatory compliance by: ensuring reviews are completed and documented in line with regulatory requirements; reviewing clinical documentation to facilitate the audit process to support compliance with coding guidelines and federal regulations; reporting cases of non-compliance; and independently identifying needs and opportunities to maintain up-to-date knowledge of relevant regulations and sharing opportunities with team members.