Clinical Documentation Integrity Specialist-Coding
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Key skills for this role
About the Role
Sheikh Shakhbout Medical City is seeking a Clinical Documentation Integrity Specialist to audit inpatient/outpatient cases for DRG validation and documentation improvement. The role requires experience in IR-DRG, ICD10, CPT, and strong coding skills, working directly with physicians and coders.
Key Skills for This Role
Responsibilities
- Prepare medical records in inpatient and/or outpatient setting to capture accurate severity of illness and facilitate proper coding
- Improve documentation practices to reflect quality and outcome scores
- Develop and educate physicians and key healthcare providers regarding clinical documentation improvement
- Obtain and promote appropriate clinical documentation through interaction with physicians
- Perform remote and on site paper or electronic medical chart review and clinical validation audits
- Facilitate and obtain appropriate physician documentation for clinical conditions or procedures
- Assess review data to determine areas of improvement for follow up physician training and communication
- Utilize query process when code assignments are not straightforward or documentation is not clear
- Maintain clinician focused process design, data analysis, and improvement strategies
- Prepare spreadsheets to collect and support chart review findings
- Recommend necessary training to correct deficiencies for the department/section
- Contribute to processes used in performance of CDS role through SOP development and revision
Requirements
- Experience in IR DRG, ICD10 and CPT
- Experience with Statistical analysis/ Data Analysis
- Experience with Microsoft Office Tools
- Experience in a large healthcare facility
- Any of the following: Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), or equivalent
Full Job Posting
Job Description
- The CDI primary role will be auditing inpatient/ outpatient cases for DRG validation and/or documentation improvement opportunities utilizing a unique approach that combines technology, coding and clinical documentation auditing expertise.
- Responsibilities include working directly with the Physicians, Coders and CDI team members to streamline processes, identify training needs and ensure consistent information is shared.
Responsibilities
- Prepares medical records in the inpatient and/or outpatient setting to capture an accurate representation of the severity of illness and facilitate proper coding.
- Improves documentation practices to reflect quality and outcome scores.
- Develops and educate physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record;
- Obtains and promote appropriate clinical documentation through extensive interaction with physicians to ensure that the documentation of the level of service rendered to the patient and the patient's clinical complexity is complete and accurate;
- Performs remote and on site paper or electronic medical chart review and clinical validation audits and interpretation of medical documentation to ensure clinical support of all relevant coding based on AHIMA guidelines;
- Facilitates and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient
- Assess review data to determine areas of improvement for follow up physician training and communication
- Utilizes query process when code assignments are not straightforward or documentation is not clear for coding purposes;
- Maintains Clinician focused process design, data analysis, and improvement strategies to drive project execution for high quality/high priority outcomes;
- Assess clinical aspects of medical record documentation to drive improvement and consistency in application across Medical Group adult primary care and specialty clinics.
- Prepares spreadsheets to collect and support chart review findings;
- Recommends necessary training to correct deficiencies for the department/section
Qualifications
- Required: Experience in IR DRG, ICD10 and CPT
- Required: Experience with Statistical analysis/ Data Analysis
- Required: Experience with Microsoft Office Tools
- Required: Experience in a large healthcare facility
- Desired: Experience in a large healthcare facility
- Desired: Experience in IR DRG and ICD10
- Educational Qualification: Any of the following: Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), or equivalent
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