Clinical Documentation Integrity Specialist I, Full Time, Day

Inspire health. Serve with compassion. Be the difference.

Job Summary

Reviews medical records to identify documentation opportunities to accurately represent the severity of illness, risk of mortality, length of stay, intensity of service, and hospital quality metrics. Reviews medical records, submits provider queries, and reconciles discharged records. Collaborates with Coding and other departments to facilitate the highest level of accuracy, quality, and completeness of provider documentation as well as accurate code assignment.

Essential Functions

All team members are expected to be knowledgeable and compliant with Prisma Health's values : Inspire health. Serve with compassion. Be the difference.

Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency and accuracy of clinical documentation.

Employs the query process as needed to provide accurate documentation reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.

Completes the reconciliation process to ensure accurate coding reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.

Develops and maintains supportive, collaborative relationships with providers and health care team members to include education and follow up.

Stay current with coding guideline changes, changes in treatment modalities, clinical disease indicators, and compliant query policies.

Serves as a resource for co-workers, providers, and other support departments (coding, case management, quality, nutrition, etc.)

Assigns a working DRG for health care team discharge planning and CDI use.

Performs other duties as assigned

Supervisory / Management Responsibilities

This is a non-management job that will report to a supervisor, manager, director or executive.

Minimum Requirements

Education - Associate degree in Nursing, Health Information Management, or related field of study

Experience - Two (2) years -adult medical / surgical / critical care / ER / PACU nursing coding or related experience

In Lieu Of

In lieu of the education and experience requirements noted above, the following combination of education, training and / or experience may be considered an equivalent substitution : MD / DO / PA / NP

Required Certifications, Registrations, Licenses

RN / RHIA / RHIT / CCS / CIC / or Licensure in related field of study

Knowledge, Skills and Abilities

Strong computer skills

Strong communication skills with ability to interact with providers.

General knowledge of IPPS, ICD10 Coding, MS-DRG / APR-DRG and HCPCS coding systems preferred

Work Shift

Day (United States of America)

Location

Corporate

Facility

7001 Corporate

Department

70017540 Clinical Documentation Integrity

Share your talent with us! Our vision is simple : to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.