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Clinical Documentation Integrity - Washington, United States - Medstar
Description
General Summary of PositionThe Clinical Documentation Integrity (CDI) Auditor is responsible for providing expert second level review to ensure the quality and integrity of medical records.
Responsibility includes validating ICD-10-CM/PCS codes by examining medical record documentation of clinical findings, care rendered, and the assignment of present on admission (POA) indicators and discharge disposition status for claims under review.
The auditor works directly with the CDI Manager and Clinical Documentation Specialists (CDS) to streamline processes, identify training needs and ensure consistent information is shared.
Serves as an expert resource for all CDI and coding staff on MS-DRG and APR-DRG payment methodologies as well as coding guidelines and regulatory requirements governing queries.
Exemplifies the mission, vision and values of MedStar Georgetown University Hospital (MGUH)and acts in accordance with MGUH policies and proceduresPrimary Duties and Responsibilities
Evaluates- concurrently and retrospectively- inpatient medical records reviewed by CDS for completeness, accuracy to validate that the clinical documentation supports the assigned ICD-10-CM/PCS codes, the selection of the principal diagnosis and discharge disposition following CMS requirements and Coding Clinic guidance
Conducts second level reviews for MGUH approved CDI/HIM work queues and identifies missed query opportunities on conditions necessitating additional clarification within the medical record.
This includes quality indicators and risk adjustment conditions.Audits work product and query compliance by CDS staff using a standard tool.
Provides education to CDS based on audit results regarding query compliance, opportunities for diagnosis clarification and accuracy to improve documentation integrity.
Serves as a resource to the CDS staff and ensures adherence to official coding guidelines.Utilizes data analytics and algorithms to perform prebill or post bill DRG and Clinical Validation reviews to identify revenue integrity issues and opportunities to improve quality metrics.
Assists the CDI manager in maintaining work queues for bundled DRG's, mortality records and all charts deemed to require a second level review.
Assists the CDI manager in educating physicians and other clinicians to facilitate documentation within the medical record to reflect the most accurate severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, and level of service renderedAssists the CDI manager with developing specific departmental goals and objectives, policies, standards and workflow procedures which directly support the strategic plan for the CDI program and MGUH.
Works with other stakeholders to assist in the development and implementation of training materials related to clinical documentation, ICD-10, quality measures, and other topics as needed.
Reviews and writes appeals for clinical validation external denials, as applicable, and provides feedback to the coding and CDI staff and physician advisors.
Maintain a working knowledge of new coding and DRG guidelines and regulations.Assists the CDI manager in developing and maintaining reporting tools specific to productivity and quality outcomes.
Assists the CDI Manager with orientation of new CDS staff and in continued professional development of experienced CDS staff.
Acts as an effective liaison between the CDI and coding teams and management as required.
Assumes other duties and responsibilities that are appropriate to the position and area.
The above responsibilities are a general description of the level and nature of the work assigned to this classification and is not to be considered as all-inclusive.
Minimum Qualifications
Education
Bachelor's degree B.S. degree in a health care related field required
Experience
Licenses and Certifications
RN - Registered Nurse - State Licensure and/or Compact State Licensure or
Certified Expert Coder-AHIMA or AAPC
CDIP - Clinical Documentation Improvement Professional
Knowledge, Skills, and Abilities
Excellent knowledge of clinical documentation integrity and coding
Must be able to manipulate and analyze statistical data.
Must have excellent communication (written and verbal) skills.
Must be able to work with all levels of personnel within the Hospital.
Quality improvement process skills
Proficient in the use of computers to perform daily work including Microsoft Office (Word, Excel, PowerPoint, etc.).
Ability to collect and analyze data related to the CDI program
Excellent interpersonal skills, with an ability to collaborate effectively with physicians, nurses and members of the health care team
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 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.
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