Clinical Documentation Integrity Specialist I, Full Time, Day

Overview

Clinical Documentation Integrity Specialist I, Full Time, Day

Join to apply for the Clinical Documentation Integrity Specialist I, Full Time, Day role at Prisma Health.

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 patients 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 patients severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and POA status.
• Develops and maintains supportive, collaborative relationships with providers and health care team members to include education and follow up.
• Stays 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

Minimum Requirements

In Lieu Of

Required Certifications, Registrations, Licenses

Knowledge, Skills And Abilities

Work Schedule

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.

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