Clinical Documentation Integrity Lead
Employee
–
06/11/24
Clinical Documentation Integrity Lead
Location: CA-Sacramento
Job Description:
Bay Administration
Position Overview:
Includes both primary and second-level chart review. Ensures the appropriate distribution of prioritized cases to team members, with careful consideration of the daily census and adequate unit coverage. Serves as a team preceptor, assisting with immediate questions related to chart review and query formulation. Performs disputed case reviews and identifies documentation gaps. Performs ad hoc chart reviews and generates reports for leadership. Co-leads the task force activities and gathers accurate data about the team’s performance for task force meetings. Helps to optimize the query process related to documentation to improve the capture of diagnoses related to nutritional status and skin integrity.
Job Description :
These Principal Accountabilities, Requirements and Qualifications are not exhaustive, but are merely the most descriptive of the current job. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development).
JOB ACCOUNTABILITIES:
CDI staff member performing essential CDI specialist functions, including concurrent and retrospective CDI chart reviews, assessing medical record data and provider documentation for opportunities to clarify disease specificity and capture the most accurate severity of illness, risk of mortality, and appropriate Diagnosis Related Group (DRG) assignment for each inpatient admission. Submits provider queries for clinical indicators without formal diagnoses in assessments and plans, as well as sending clinical validation queries
Prioritizes new cases daily to each team member by ensuring charts with targeted conditions or pending queries are reviewed early in each team member’s working day.
Reviews Coding/ CDI disputed cases and assists with the escalation of concurrent queries. Trains CDI team members as needed with specific strategies for composing compliant queries and identifying the best provider query recipient
Utilizes results of query audit reviews to provide targeted educational feedback to CDI team members. Tracks team members potentially requiring additional CDI educational support or remediation
Monitors the team’s daily concurrent chart review progress and volume of queries to ensure an optimized CDI workflow
Ensures appropriate capture of clinical severity as evidenced by nutritional status, leading the CDI team’s efficient provider query process for diagnoses that appear only in Registered Dietician documentation
Precepts newer team members and any team member requiring a specific skill to be improved. Demonstrates best CDI practices per Association of Clinical Documentation Integrity Specialists (ACDIS) and American Health Information Management Association (AHIMA) guidelines and reviews draft queries. Tracks team member progress
Co-leads task force meetings and helps to prepare meeting material
Works to create report content for CDI departmental initiatives related to monitors the daily workflow and specific cases for representative examples supporting CDI management reports
EDUCATION:
Bachelor’s: Nursing
CERTIFICATION & LICENSURE:
RN-Registered Nurse of California
OR DO-Doctor of Osteopathy
OR MD-Doctor of Medicine
OR Foreign trained physician
CCS-Certified Coding Specialist
CCDS or CDIP-Certified Clinical Documentation Specialist
TYPICAL EXPERIENCE:
8 years recent relevant experience.
SKILLS AND KNOWLEDGE:
Knowledge of Pathophysiology and Disease Processes sufficient to pass the clinical pre-employment test at a rate of 85% or better is required.
Up-to-date knowledge of ICD-10 mandate and the impact of code set transition, including potential impact on data quality for prospective payments, utilization, and reimbursement.
Strong Organization and Quantitative Analysis skills including spreadsheet applications and statistics.
Excellent verbal and written communication skills required. Must be able to communicate effectively with a diverse group of individuals and departments, including members of the medical staff.
Dependable with a demonstrated ability to efficiently and independently manage own time and tasks with minimal supervision.
Willingness to act and dress in a professional manner at all times.
Able to manage multiple priorities and meet productivity targets
Critical thinking, problem solving and deductive reasoning skills
Demonstrated familiarity and adept use with software and technical applications including but not limited to: Microsoft Office products (Outlook, Excel, Word, PowerPoint) and Epic (Electronic Health Records).
Understand and support CDI documentation strategies (upon completion of training)
Ability to understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments (upon completion of training)
High degree of hospital coding knowledge, including but not limited to APR-DRG, MS-DRG, HCCs, Medicare, Medicaid & Managed Care, in order to design and develop strategies to yield improvements to documentation that will improve overall patient quality, capture severity, assess acuity and determine risk of mortality.
Thorough knowledge of clinical documentation requirements, clinical procedures, disease processes, treatments, and the patient populations served.
Subject matter expertise regarding quality and reimbursement implications of clinical documentation and coding.
Provides constructive feedback and promotes team collaboration along with guidance and CDS mentorship.
Collaborate to perform root cause analysis and assist with ongoing opportunities for process improvement.
Reviews HAC/PSI database content weekly to support CDS account review
PHYSICAL ACTIVITIES AND REQUIREMENTS:
See required physical demands, mental components, visual activities & working conditions at the following link: Job Requirements (https://sutterhealth.sharepoint.com/:b:/s/JobAnalysisLibrary/ERB-IcsfFyhBhpp4HJcgNqEBFRddckIt9zQxcajIATM7iA?e=xcUfQf)
Job Shift :
Days
Schedule :
Full Time
Shift Hours:
8
Days of the Week:
Friday, Monday, Thursday, Tuesday, Wednesday
Weekend Requirements:
None
Benefits:
Yes
Unions:
No
This position is work from home eligible.
Position Status:
Non-Exempt
Weekly Hours:
40
Employee Status:
Regular
Number of Openings:
1
Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.
Pay Range is $87.49 to $115.48 / hour
The salary range for this role may vary above or below the posted range as determined by location. This range has not been adjusted for any specific geographic differential applicable by area where the position may be filled. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, department equity, training and organizational needs. Base pay is just one piece of the total rewards program offered by Sutter Health. Eligible roles also qualify for a comprehensive benefits package.
All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, marital status, sexual orientation, registered domestic partner status, sex, gender, gender identity or expression, ancestry, national origin (including possession of a driver’s license issued to individuals who did not present proof of authorized presence in the U.S.), age, medical condition, physical or mental disability, military or protected veteran status, political affiliation, pregnancy or perceived pregnancy, childbirth, breastfeeding or related medical condition, genetic information or any other characteristic made unlawful by local, state, or federal law, ordinance or regulation. External hires must pass a background check/drug screening. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state, and local laws, including but not limited to the San Francisco Fair Chance Ordinance.