Clinical Documentation Integrity Specialist

🔥 7 minutes ago

🏈 Ohio – Remote

🏈 Ohio – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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University Hospitals

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

📚 Education

💰 $2M Grant on 2021-07

Healthcare • Medical Services • Education

University Hospitals is a leading healthcare provider that offers a wide range of medical services, including primary care, specialty care, and urgent care. With a focus on patient-centered care, UH also engages in medical education and research, ensuring high-quality treatment and innovative healthcare solutions. The institution is recognized nationally for its excellence in various medical specialties, providing accessible healthcare to the community and beyond.

📋 Description

• Facilitate the integrity, quality, accuracy, and completeness of provider-based clinical documentation in medical records • Collaborate with healthcare providers and clinical teams to ensure documentation accurately reflects patients • Review medical records and identify opportunities for improved or clarified documentation • Follow up with clinical providers to obtain requested clarification • Maintain current CDI and coding knowledge, including research, technology, treatment modalities, Coding Clinics, AHIMA, and CMS guidelines • Identify query opportunities and write AHIMA-compliant physician queries • Escalate non-response to queries according to policy • Collaborate with the coding team • Educate physicians and clinical care providers through rounding, service-line sessions, and case-specific feedback • Apply healthcare workflow knowledge to improve medical record documentation and quality-outcome reporting • Meet productivity, quality, and AHIMA ethical standards using the CDI business platform • For inpatient work: review encounters, determine working DRGs, assess SOI/ROM cases, identify HAC/PSI queries, and reduce DRG downgrade and denial risks • For outpatient work: research missing charges, coordinate with Coding/CDM/Finance, analyze clinical and billing data, maintain project plans, track revenue indicators, and audit defined areas • Perform other assigned duties and comply with policies and PHI requirements

🎯 Requirements

• Associate's Degree in health related field (Required) or Diploma in Nursing from an accredited program (Required) • 3+ years clinical and/or ICD-10 coding experience, preferably in a large academic medical center (Required) • 1+ years experience using clinical computer systems (Required) • Thorough, up-to-date clinical skills, including pathology, pharmacology, and surgical procedures • Excellent written and verbal communication skills, including presentations • Ability to function independently and as a team player in a fast-paced environment • Detail-oriented and relationship-building skills • Extensive knowledge of disease pathophysiology • Registered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire), or RHIA (Required Upon Hire), or RHIT (Required Upon Hire) • Must safely and securely maintain Protected Health Information (PHI) • 10% travel requirement