Clinical Documentation Integrity Specialist

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🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Inova Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Inova is Northern Virginia’s leading nonprofit healthcare provider, offering world-class clinical excellence to everyone in our communities with a warm, human touch. Our 22,000+ team members collaborate to achieve individual and group health goals in partnership with every one of the 2M+ individuals we’re privileged to serve annually, treating across specialties from cancer to neurology to gynecology, neonatal care and much more. The results speak for themselves: Inova’s care is consistently recognized by the Centers for Medicare and Medicaid Services (CMS), U.S. News & World Report Best Hospitals, Leapfrog Hospital Safety Grades for excellence and the American Nurses Credentialing Center. Whether helping all stay healthy, treating illness or repairing injury, we have the skills and compassion to meet every need. We are Inova: your healthcare partner, for your life.

📋 Description

• Performs initial case reviews and an appropriate number of follow-up reviews based on program standards. Uses clinical insight and judgment of clinical findings to assess clinical documentation for improvement opportunities. Independently develops complex queries. • Maintains query rate, response rate, and agreement rate in line with established performance benchmarks. • Assists with reviewing records at different Inova hospitals as needed and under the supervision of assigned CDI leaders. • Participates in all department-wide CDI and coding education on ICD-10, MS-DRG, and quality outcome measures as well as compliance requirements related to query (AHIMA Practice brief). • Maintains competency in the use of CDI applications to process daily work lists and report results of record reviews and queries. • Enters all required data into CDI applications to enable Coding professionals and Coding Quality Coordinators to determine the disposition of concurrent queries in order to assign the final MS-DRG as well as APR-DRG, SOI, and ROM and risk adjustment factors. • Demonstrates expert knowledge of ICD 10 codes and MS-DRG/APR DRG assignments. • Interacts with Coding Quality Coordinators and Coding professionals on any questions related to CDI working DRG related to concurrent queries and final coding. • Assists with any post-discharge (retrospective) queries per CDI policy/procedure and as requested by CDI leadership. • Demonstrates advanced technical ability with current software used by the department. • Provides electronic support to providers regarding best practice documentation standards and the query process. Provides 1:1 provider education within the daily workflow and participates in group education sessions as requested by CDI Leadership. • Participates in special projects, audits, and other duties as directed by CDI Leadership. May assist with precepting and education of new staff. • Works collaboratively with medical, nursing, and ancillary staff to improve the quality of chart documentation that assures appropriate DRG classification to accurately reflect patient severity of illness and risk of mortality. • Participates, and takes a leadership role in, select special projects, audits, and other duties as directed by CDI Leadership. • As needed, may travel across the Washington DC metro area to engage with providers. • May perform additional duties as assigned.

🎯 Requirements

• Education: Associate Degree (RN, MD, RHIA/RHIT) • Experience: Five years of professional inpatient acute care, inpatient clinical, and/or coding experience required. Includes ICU, ER, Peds/NICU, case management/UR, quality or similar level of advanced care/coding. • Two years of CDI experience in an acute inpatient healthcare setting. • Certification: CDI certification (CCDS or CDIP) • Licensure: RN, RHIT, or foreign medical school licensure documentation equivalent to educational background required.

🏖️ Benefits

• Committed to Team Member Health: offering medical, dental and vision coverage, and a robust team member wellness program. • Retirement: Inova matches the first 5% of eligible contributions – starting on your first day. • Tuition and Student Loan Assistance: offering up to $5,250 per year in education assistance and up to $10,000 for student loans. • Mental Health Support: offering all Inova team members, their spouses/partners, and their children 25 mental health coaching or therapy sessions, per person, per year, at no cost. • Work/Life Balance: offering paid time off, paid parental leave, flexible work schedules, and remote and hybrid career opportunities.