Clinical Documentation Integrity Specialist - Inpatient

Clinical Documentation Integrity Specialist

Under the supervision of HIM & Professional Coding, Clinical Documentation Integrity and Denial Management Manager, the Clinical Documentation Integrity Specialist is responsible for improving the overall quality and completeness of clinical documentation. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risks of mortality, and complexity of care of the patient. Exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions or procedures. Educates members of the patient care team regarding documentation guidelines, including attending physicians, consulting physicians, allied health practitioners, nursing, and case management.

Strives for superior performance by consistently providing a product or service to leadership and staff that is recognized as ultimately contributing to the patient and family experience. Recognizes and demonstrates understanding of patient and family centered care.

Responsible To: HIM & Professional Coding, Clinical Documentation Integrity and Denial Management Manager

Workers Supervised: None.

Inter-Relationships: All departments, medical staff, patients and families and Internal and external customers.

Primary Job Responsibilities

1. Demonstrates knowledge of and supports hospital mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality statements, corporate compliance plan, customer service standards, and the code of ethical behavior.
2. Follows guidelines for coding and documentation to ensure physicians and hospital compliance. Remains current with coding information to ensure accuracy of codes assigned based on documentation. Guides, supports, and sponsors concurrent clinical coding. Provides clinical interpretation of physician documentation. Acts as a liaison between the clinical and coding functions.
3. Completes initial review of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness; and (b) initiate a review worksheet.
4. Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final DRG assignment upon patient discharge, as necessary.
5. Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed. Comply with industry standards "Guidelines for Achieving a Compliant Query Practice" when composing queries.
6. Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
7. Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.
8. Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
9. Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
10. Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues through daily and retrospective documentation reviews and aggregate data analysis.
11. Facilitates change processes required to capture needed documentation, such as forms redesign.
12. Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality.
13. Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, severity of illness, and/or risk of mortality.
14. Assists in the appeal process resulting from third-party reviews.
15. Other Focus Areas in ED & Surgery: (a) ED CDI focuses on injection/infusion times, capture diagnosis to the highest specificity and medical necessity for tests. Conduct real‑time or concurrent reviews of ED records to identify documentation gaps related to diagnoses, clinical indicators, severity of illness, and risk of mortality. Monitor documentation for high‑impact conditions such as sepsis, stroke, trauma, cardiac events, and other time‑sensitive diagnoses. (b) Same‑Day Surgery CDI focuses on ensuring documentation for ambulatory surgical procedures is accurate, capture diagnosis to the highest specificity, supports medical necessity, and clearly reflects the procedure performed. It reviews pre‑op, intra‑op, and post‑op notes to confirm diagnosis specificity, laterality, findings, and implant use, helping prevent denials and ensuring correct CPT/APC assignment.
16. Performs other job-related duties as assigned.

Job Specifications

Education

1. Associate or Bachelor degree in HIM, nursing, or a related clinical field is required.
2. Registered Nurse (RN) or RHIT (Registered Health Information Technician) or Certified Documentation Integrity Practitioner (CDIP) or CCDS (Certified Clinical Documentation Specialist) or CCS (Certified Coding Specialist) is required.
3. Coding and CDI experience is strongly preferred. Demonstrated knowledge of DRG, ICD-10 coding principles or willingness to learn through approved training.

Experience

1. Five (5) years of clinical experience in an acute care hospital setting.
2. Knowledge of ICD-10-CM, ICD-10-PCS, MS-DRG group assignments, anatomy, physiology and pathophysiology.
3. Competency in the use of computer applications.

Essential Physical Requirements/Motor Skills

1. Able to travel independently throughout all Memorial Healthcare facilities.
2. Small motor skills required for operating modern computer, office, and telephone equipment as utilized by Memorial Healthcare (MHC).
3. Able to sit for extended periods of time.

Essential Mental Abilities

1. Ability to adapt and maintain focus in fast paced, quickly changing or stressful situations.
2. Ability to read and interpret a variety of documents including, but not limited to, policies operating instructions, white papers, regulations, rules and laws.
3. Able to handle difficult and sensitive situations tactfully.
4. Able to follow instructions to learn work routines and problem solve.
5. Able to concentrate and maintain accuracy with frequent interruptions.
6. Must be self-motivated with the ability to work independently.
7. Must be able to code accurately and rapidly.
8. Ability to master basic math skills.

Essential Technical Abilities

1. Proficiency using modern office, computer and telephone equipment as used by Memorial Healthcare.
2. Motor skills required to page through hard copy and computerized records, open and close equipment, paper boxes, use typical medical office equipment.

Essential Sensory Requirements

1. Able to see for the purpose of reading information received in formats including but not limited to paper, computer, reports, bulletins, updates, manuals.
2. Able to hear for work-related purposes.
3. Ability to communicate through written and verbal communications receptively, expressively, with professionalism.

Interpersonal Skills

1. Ability to interact with co-works, hospital staff, administration, patients, physicians, the public and all internal and external customers in a professional and effective, courteous and tactful manner, at all time, physically, verbally and in all written and electronic communication.
2. Required to remain calm when adversity is encountered.
3. Open, honest, and tactful communication skills.
4. Ability to work as a team member in all activities.
5. Positive, cooperative and motived attitude.