- 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 rendered
- Assists 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.
- Bachelor's degree B.S. degree in a health care related field required
- RN - Registered Nurse - State Licensure and/or Compact State Licensure or
- Certified Expert Coder-AHIMA or AAPC
- CDIP - Clinical Documentation Improvement Professional
- 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
- 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.
-
Document Integrator
4 days ago
SMA Washington, United StatesThe Opportunity: Document Integrator / Desktop Publisher · Document Integrator / Desktop Publisher: A Document Integrator/ Desktop Publisher has demonstrated experience and expertise in integrating multiple documents and various graphics formats into one composite document, pr ...
-
Clinical Documentation Integrity
1 week ago
MEDSTAR HEALTH Washington, United States**General Summary of Position** · The 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 ...
-
Clinical Documentation Integrity
3 weeks ago
Medstar Washington, United StatesGeneral Summary of Position The 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 docume ...
-
Clinical Documentation Integrity Specialist
2 weeks ago
Med-Metrix Arlington, United StatesJob Type · Full-time · Description · Job Purpose · The Clinical Documentation Integrity Specialist focuses on the accuracy, completeness and consistency of inpatient clinical documentation to support coding and reporting of high-quality healthcare data. The Clinical Documentat ...
-
Clinical Integration Technical Lead
3 weeks ago
Program Management Solutions, LLC Washington, United StatesProgram Management Solutions is seeking a Clinical Integration Technical Lead, with knowledge of Army medical care procedures and experience providing advice and consultation to software development and integration processes to join our team. This position is remote with occasion ...
-
Oracle P2p and Prism Sme
2 weeks ago
i360technologies Washington, United States**Company Description** · - Expertise with Oracle Procure to Pay and its integration with PRISM. · - Expert understanding of PO / AP configurations, SLA. · - Provide standards of federal AP and PO business process as it relates to Oracle R12. · - Functional SME with expertise in ...
-
Logistics Analyst
3 weeks ago
Serco North America Washington, United StatesPosition Description: · If you seek a rewarding, high profile and challenging position supporting projects for the US Navy which requires technical rigor and will tap and build on your expertise, -Serco has a wonderful opportunity for you The Integrated Logistics Systems (ILS) Sp ...
-
Domestic Ice Ims
2 weeks ago
TMMG Washington, United States**Position: (C) Domestic Ice IMS & IGS Manager ** · **Labor Category**:SME Business and Financial Operations Specialist Group 3** · **Location: Washington, DC/Hyrid **(TBD)** · **Days: Monday thru Friday** · **Hours: Full Time - 40 Hours/Week** · **Travel: <10%** · **Relocation A ...
-
Human Resources(HR Processing Unit)
2 weeks ago
Business Management Associates, Inc. Washington, United States**Business Management Associates, Inc. (BMA)** Integrating People and Process Through Service, with a strategic emphasis on integrating people and process, and proven, documented project management methodology for internal and external management while maintaining a strategic and ...
-
Financial Analyst Ii
2 weeks ago
APA, LLC Washington, United States**Financial Analyst II** · **Washington D.C.** · **Description**: · - Provide assistance in researching and writing responses to comptroller, DASN, OPNAV, Congressional and other higher-level authority questions and inquiries. · - Support development, coordination, and/or review ...
-
Document Scanning
2 weeks ago
Imaging Office Systems, Inc Columbia City, United States**NOW HIRING** · **Document Scan Operators & Quality Control Associates** · - Imaging Office Systems Inc. is the foremost single-source provider of content management and data technology for business. That means if it's digital, we connect our clients to it, or help them capture ...
-
Operation Analyst
2 weeks ago
IFC Systems Corporation Washington, United States**Operation Analyst** · **Job #**: · - req27229**Organization**: · - World Bank**Sector**: · - Operations**Grade**: · - GE**Term Duration**: · - 2 years 0 months**Recruitment Type**: · - Local Recruitment**Location**: · - Washington, DC,United States**Required Language(s)**: · - ...
-
Technical Consultant
2 weeks ago
Everbridge Washington, United StatesThe Technical Consultant reporting to the Professional Services leader, the Technical Consultant will operate in a collaborative, team-focused environment, ensuring adherence to our strict quality control and program delivery methodology. · - The role requires project management ...
-
Logistics Sustainment Support Specialist
3 weeks ago
IQUASAR LLC Washington, United States Full time**Benefits**: · - 401(k) · - 401(k) matching · - Competitive salary · - Dental insurance · - Paid time off · - Parental leave · KMS Solutions, LLC is a technical management/solutions company that specializes in engineering, analysis, and cyber security. Founded in 2005, KMS is a ...
-
Operation Analyst
2 weeks ago
World Bank Group Washington, United States**Job #**: · - req27229**Organization**: · - World Bank**Sector**: · - Operations**Grade**: · - GE**Term Duration**: · - 2 years 0 months**Recruitment Type**: · - Local Recruitment**Location**: · - Washington, DC,United States**Required Language(s)**: · - English, Spanish**Prefer ...
-
Microsoft Sharepoint Farm Administrator
3 weeks ago
SiloSmashers Washington, United StatesGENERAL POSITION DESCRIPTION · ROLE RESPONSIBILITIES · - Provides support for implementation, troubleshooting and maintenance of IT systems including and integrating with SharePoint on-premises. · - Manages integrated system infrastructure and any processes related to these syste ...
-
Program Associate
3 weeks ago
ZemiTek LLC Washington, United StatesWho We Are: · ZemiTek, LLC is a Woman-Owned, SBA-certified 8(a) Small Disadvantaged Business (SDB) based in the Washington, DC metro area. We have a strong record delivering innovative and high-quality solutions. Since 2007, ZemiTek has provided technical assistance, project mana ...
-
Oracle Application Integration Consultant
3 weeks ago
CSZ Net Inc Washington, United States**Hi,** · **Please let me know your interest in the below position.** · **Role: Senior Oracle Application Integration Consultant** · **Location: Washington, DC** · **Duration: 12 months contract** · **Job ID: OCTO Senior Application Integration Consultant -** **734677** · **Clien ...
-
Ada Consultant
2 weeks ago
Business Management Associates, Inc. Washington, United States**Business Management Associates, Inc. (BMA)** Integrating People and Process Through Service, with a strategic emphasis on integrating people and process, and proven, documented project management methodology for internal and external management while maintaining a strategic and ...
-
Knowledge Base Management System Support
2 weeks ago
ActioNet Washington, United StatesActioNet is looking for a **Knowledge Base Management System Support**. ActioNet is an IT service provider and solutions integrator headquartered in Vienna, VA that works with the Federal Government. · As the **Knowledge Base Management System Support**, you will be responsible f ...
Clinical Documentation Integrity - Washington, United States - MEDSTAR HEALTH
Description
General Summary of Position
The 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 procedures
Primary Duties and Responsibilities
Minimum Qualifications
Education
Experience
Licenses and Certifications
Knowledge, Skills, and Abilities
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:
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.