Clinical Documentation Integrity Specialist - Full Time - 40 Hours - Days
Henry Ford Health · Troy, MI · 4 days ago
AdministrativeFull-time
Principle Duties And Responsibilities
- Review clinical documentation and diagnostic results in the electronic medical record (paper record during downtime) for patients within 48 hours of admission to ensure that signs, symptoms, diagnoses, and response to treatment are accurately documented and the medical record reflects the patient’s severity of illness, risk of mortality, and resource consumption.
- Use clinical experience and knowledge of ICD-10-CM Coding Guidelines to identify opportunities to clarify documentation.
- Formulate compliant queries and adhere to approved process for query resolution.
- Collaborate with coding on retrospective reviews and queries.
- Perform reconciliation reviews to ensure query impact is captured and recorded correctly.
- Review CDI/Coding DRG mismatches and follow approved process for resolution.
- Conduct follow-up reviews to assess for accuracy and completeness of new documentation and identify new query opportunities.
- Collaborate with Quality teams to ensure documentation supports compliance with quality pathways and initiatives.
Education/Experience Required
- Registered Nurse (RN), BSN preferred, OR Certified Nurse Practitioner (CNP) or Physician Assistant (PA-C), OR International Medical Graduate.
- Demonstrated clinical competence as evidenced by 3-5 years clinical experience in one of the above roles in an acute care setting, preferably critical care.
- Basic PC knowledge required.
- Knowledge of ICD-10-CM Coding Guidelines.
- Knowledge of revenue cycle process preferred.
- Knowledge of health care fiscal management goals and strategies preferred, including, but not limited to trends and issues in health care reimbursement.
Education/Experience Required
- Certifications/Licensures Required:
- Current Registered Nurse (RN) license, OR Current Certified Nurse Practitioner (CNP) or Physician Assistant (PA-C) license, OR Current Educational Commission for Foreign Medical Graduates (ECFMG) credentials.