Clinical Integration Specialist RN, Documentation, CDI coding

Downey, California
Mar 16, 2024
Apr 14, 2024
Job Summary:

This position uses clinical knowledge and knowledge of coded data for documentation requirements to improve overall patient quality, capture severity, acuity and risk of mortality. This position includes the ability to perform concurrent and retrospective reviews of inpatient medical records to evaluate clinical documentation for integrity and proper documentation of patient care. In addition, will need to have expertise in understanding the clinical documentation required for the completeness of the patient records using a multidisciplinary team process. The specialist will also work with the medical staff to facilitate appropriate clinical documentation of patient care. Also, perform core measure reviews, patient classification, and continued stay reviews.

Essential Responsibilities:

  • Facilitates appropriate clinical documentation to support diagnosis capture and to ensure the level of service rendered to all patients is recorded.

    • Identifies and reviews primary and secondary diagnosis and complications to ensure diagnosis documentation and capture through addendums may identify patients who need to be seen.

      • Identify and review for POA (Present on Admission) documentation. Reviews clinical issues with medical coding staff and with physicians to identify those diagnoses that impact severity of illness indicators for each patient.

        • Perform CDI reviews - concurrent, pre-bill and retrospective. Serves as an expert resource in reviewing all medical records in support of consistent documentation for all payer types (i.e. CMS, Medicare-Advantage, etc.) to ensure complete and accurate diagnosis capture and coding. This would include core measures and patient classifications and/or continued stay.

          • Reviews would include: 1) Identifying evidence of appropriate documentation of medical necessity to support the treatment plan and compliance with regulatory requirements and standards. 2) The documentation reviewed may include, but is not limited to: admission order, H&P, consultation, operative report, discharge summary, progress note, medication orders, and emergency department report. 3) Reviews for completeness, contradictions, omissions, and accuracy of medical, surgical, pathological, pharmaceutical and diagnostic documentation.

            • Collaborates in the development of programs which provide alignment with education for internal customers to support clinical documentation guidelines. Communicates information effectively with medical center leaders.

              • Works with Coding Supervisor to develop, implement and monitor departmental policies and procedures that support organizational goals, business objectives, regulatory needs and requirements. Conducts data and root cause analysis, provides feedback and shares findings on the analysis to leaders, local regional management and medical team. Report all issues timely to Director, Health Information Management. Monitor and track verbal and written queries and produce reports as required.

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