Documentation Integrity Specialist 4 - Clinical Licensure

Reviews a moderate caseload of medical/health records to promote the accuracy and completeness of clinical documentation and assigns medical codes and diagnostics-related groups (DRGs) to facilitate the accurate capture of diagnoses. Assists in enhancing the clinical documentation improvement/integrity (CDI) program by integrating processes to improve the accuracy and completeness of clinical documentation and documentation issue resolution. Supports regulatory compliance by aiding audits, reviewing clinical documentation, and documenting cases of non-compliance in line with coding guidelines and federal regulations. Collaborates with others to conduct staff trainings and education on clinical documentation improvement (e.g., medical review and coding, quality standards, documentation requirements for diagnosis capture).

• Promotes learning in others by proactively providing and/or developing information, resources, advice, and expertise with coworkers and members; builds relationships with cross-functional/external stakeholders and customers. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to others and to managers. Pursues self-development; creates and executes plans to capitalize on strengths and develop weaknesses; leads by influencing others through technical explanations and examples and provides options and recommendations. Adopts new responsibilities; adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support a business outcome.
• Completes work assignments autonomously and supports business-specific projects by applying expertise in subject area and business knowledge to generate creative solutions; encourages team members to adapt to and follow all procedures and policies. Collaborates cross-functionally and/or externally to achieve effective business decisions; provides recommendations and solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Supports the development of work plans to meet business priorities and deadlines; identifies resources to accomplish priorities and deadlines. Identifies, speaks up, and capitalizes on improvement opportunities across teams; uses influence to guide others and engages stakeholders to achieve appropriate solutions.
• Works on clinical documentation reviews by\: reviewing a moderate caseload of medical/health records to promote accuracy and completeness of clinical documentation; reviewing results of a moderate to large caseload of medical record reviews and working alongside others to rectify identified omissions or contradictions in medical records; completing medical codes and diagnostics-related groups (DRGs) to facilitate the accurate capture of diagnoses in collaboration with senior team members and leadership; contributing to the identification of medical conditions that impact the severity of illness (SOI) and risk of mortality (ROM) indicators; and monitoring the documentation clarification queries to support efficient resolution of open queries.
• Integrates processes to improve clinical documentation by\: supporting reviews of clinical documentation improvement/integrity (CDI) programs and integrating processes to improve the accuracy and completeness of clinical documentation and documentation issue resolution; determining areas to improve clinical review and documentation processes; and collaborating with team members to identify and implement documentation improvement initiatives.
• Conducts staff training and education by\: collaborating with others on CDI training (e.g., medical review and coding, quality standards, documentation requirements for diagnosis capture); and working with others to determine areas of improvement and collaborate with senior professionals to develop programs for clinical documentation education/training.
• Drives regulatory compliance by\: completing reviews and documenting in line with regulatory requirements; following established procedures to perform audits of clinical documentation to support compliance with federal, state, and local regulations; documenting cases of non-compliance; and working with others to maintain up-to-date knowledge of relevant regulations and sharing opportunities with team members.

Reviews a moderate caseload of medical/health records to promote the accuracy and completeness of clinical documentation and assigns medical codes and diagnostics-related groups (DRGs) to facilitate the accurate capture of diagnoses. Assists in enhancing the clinical documentation improvement/integrity (CDI) program by integrating processes to improve the accuracy and completeness of clinical documentation and documentation issue resolution. Supports regulatory compliance by aiding audits, reviewing clinical documentation, and documenting cases of non-compliance in line with coding guidelines and federal regulations. Collaborates with others to conduct staff trainings and education on clinical documentation improvement (e.g., medical review and coding, quality standards, documentation requirements for diagnosis capture).

• Promotes learning in others by proactively providing and/or developing information, resources, advice, and expertise with coworkers and members; builds relationships with cross-functional/external stakeholders and customers. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to others and to managers. Pursues self-development; creates and executes plans to capitalize on strengths and develop weaknesses; leads by influencing others through technical explanations and examples and provides options and recommendations. Adopts new responsibilities; adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support a business outcome.
• Completes work assignments autonomously and supports business-specific projects by applying expertise in subject area and business knowledge to generate creative solutions; encourages team members to adapt to and follow all procedures and policies. Collaborates cross-functionally and/or externally to achieve effective business decisions; provides recommendations and solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Supports the development of work plans to meet business priorities and deadlines; identifies resources to accomplish priorities and deadlines. Identifies, speaks up, and capitalizes on improvement opportunities across teams; uses influence to guide others and engages stakeholders to achieve appropriate solutions.
• Works on clinical documentation reviews by\: reviewing a moderate caseload of medical/health records to promote accuracy and completeness of clinical documentation; reviewing results of a moderate to large caseload of medical record reviews and working alongside others to rectify identified omissions or contradictions in medical records; completing medical codes and diagnostics-related groups (DRGs) to facilitate the accurate capture of diagnoses in collaboration with senior team members and leadership; contributing to the identification of medical conditions that impact the severity of illness (SOI) and risk of mortality (ROM) indicators; and monitoring the documentation clarification queries to support efficient resolution of open queries.
• Integrates processes to improve clinical documentation by\: supporting reviews of clinical documentation improvement/integrity (CDI) programs and integrating processes to improve the accuracy and completeness of clinical documentation and documentation issue resolution; determining areas to improve clinical review and documentation processes; and collaborating with team members to identify and implement documentation improvement initiatives.
• Conducts staff training and education by\: collaborating with others on CDI training (e.g., medical review and coding, quality standards, documentation requirements for diagnosis capture); and working with others to determine areas of improvement and collaborate with senior professionals to develop programs for clinical documentation education/training.
• Drives regulatory compliance by\: completing reviews and documenting in line with regulatory requirements; following established procedures to perform audits of clinical documentation to support compliance with federal, state, and local regulations; documenting cases of non-compliance; and working with others to maintain up-to-date knowledge of relevant regulations and sharing opportunities with team members.

• Minimum two (2) years of experience in an inpatient acute care or clinical setting.
• Bachelors degree in Nursing, Medicine, Health Administration, Health Information Management, or related field AND minimum four (4) years experience in nursing, medicine, CDI, inpatient coding, quality review, case management, or a directly related field OR Minimum seven (7) years of experience in nursing, medicine, CDI, inpatient coding, quality review, case management, or a directly related field.

• Nurse Practitioner Certificate (California) required at hire OR Registered Nurse License (California) required at hire OR Doctor of Medicine License (California) required at hire OR Physician Assistant License (California) required at hire

• Minimum two (2) years of experience in an inpatient acute care or clinical setting.
• Bachelors degree in Nursing, Medicine, Health Administration, Health Information Management, or related field AND minimum four (4) years experience in nursing, medicine, CDI, inpatient coding, quality review, case management, or a directly related field OR Minimum seven (7) years of experience in nursing, medicine, CDI, inpatient coding, quality review, case management, or a directly related field.

• Nurse Practitioner Certificate (California) required at hire OR Registered Nurse License (California) required at hire OR Doctor of Medicine License (California) required at hire OR Physician Assistant License (California) required at hire

• Certified Clinical Documentation Specialist Credential (CCDS) from the Association of Clinical Documentation Integrity Specialists (ACDIS) OR Certified Documentation Improvement Practitioner (CDIP), Certified Coding Specialist (CCS), Certified Coding Specialist Physician-based (CCS-P), Registered Health Information Administrator (RHIA), OR Registered Health Information Technician (RHIT) from the American Health Information Management Association.
• Three (3) years of experience using Epic System software OR other Electronic Medical Record (EMR) system.

• Certified Clinical Documentation Specialist Credential (CCDS) from the Association of Clinical Documentation Integrity Specialists (ACDIS) OR Certified Documentation Improvement Practitioner (CDIP), Certified Coding Specialist (CCS), Certified Coding Specialist Physician-based (CCS-P), Registered Health Information Administrator (RHIA), OR Registered Health Information Technician (RHIT) from the American Health Information Management Association.
• Three (3) years of experience using Epic System software OR other Electronic Medical Record (EMR) system.

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