Clinical Documentation Integrity Specialist - Remote

Job Summary:

Responsible for the concurrent/retrospective review of medical record documentation. The Clinical Documentation Integrity Specialist (CDIS) reviews focus on documentation completeness, accuracy and overall entry detail to facilitate Coding/DRG assignment to best reflect the Severity of Illness, Risk of Mortality, Quality of Care, and the consumption of resources and services rendered to our patient customers.

The incumbent in this position will support the mission, vision, values and strategic initiatives of Mary Washington Healthcare and must demonstrate a commitment to quality service to patients, physicians, the public and co-workers.

• Serves as a resource to all members of the patient care team regarding documentation guidelines on an on-going basis. Queries physicians for documentation clarification as needed.
• Facilitates the overall improvement of clinical documentation completeness, accuracy, and detail related to the assignment of diagnosis and procedure codes that support the determination of the most appropriate final DRG.
• CDI efforts are based on practices/initiatives based on coding guidelines, the professional practice of Registered Nurses and CDI Specialists (ACDIS).
• Identifies and reports quality and risk opportunities as appropriate.
• Actively communicates with CDI Manager and Physician Liaison regarding program barriers/success/outcomes of CDI program.
• Participates in educational activities to improve job skills and knowledge.
• Reviews clinical issues with the coding Associates to assign a working or final DRG.
• Maintains positive open communication with physicians, interdisciplinary team members, and department leadership to effectively build partnering relationships.
• Reconciles all CDI reviews to validate DRG assignment and query response.
• Collaborates extensively with Physicians/Providers, Nursing, other patient caregivers and Coders to obtain appropriate clinical documentation specific to the individual patient encounter.
• Updates Working DRG to reflect any changes in patient status, procedures/treatments, and confers with the physician to finalize diagnoses.
• Supports the improvement of clinical documentation through practices/initiatives based on Coding Guidelines and the professional practice of CDI Specialists and Registered Nurses.
• Performs other duties as required.
• Demonstrates competency in obtaining documentation improvement modifications in accordance with all related guidelines and regulatory requirements.
• Participates on multidisciplinary teams to assist with documentation improvement efforts.
• Working knowledge of the Medicare reimbursement system preferred.

• Associates Degree in Nursing required. Bachelors Degree in Nursing or other related field is preferred.
• Previous CDI or related field experience, required.
• CCDS and/or CDIP Certification preferred.
• 3-5 years nursing experience in an acute care setting; may be optional for candidates have recent experience in CDI/Utilization Review/Care Management/Quality or other related field.
• Able to work independently with minimal supervision in a time-oriented environment.
• Ability to maintain positive open communication with physicians and interdisciplinary care team members, required.
• Current RN License in the State of Virginia or reciprocal state required.
• Proficiency with Microsoft Office (Outlook, Teams, Excel/Word etc.).Ability to work with computer systems, typing, and abstract data required.
• Experience with EPIC and/or 3M 360 preferred.
• Residency in the following states: NC, NE, FL, SC, VA, GA.
• Able to use critical thinking skills to review and interpret patient care documentation.
• Must have strong written and verbal communication skills.
• Ability to utilize their knowledge, experience, and coding expertise to assist with facilitation and documentation of the most accurate reflection of the services that were provided.