Clinical Documentation Integrity

3 weeks ago

Washington DC United States MEDSTAR HEALTH Full time

General Summary of Position
The Clinical Documentation Integrity (CDI) Auditor is responsible for providing expert second level review to ensure the quality and integrity of medical records. Responsibility includes validating ICD-10-CM/PCS codes by examining medical record documentation of clinical findings, care rendered, and the assignment of present on admission (POA) indicators and discharge disposition status for claims under review. The auditor works directly with the CDI Manager and Clinical Documentation Specialists (CDS) to streamline processes, identify training needs and ensure consistent information is shared. Serves as an expert resource for all CDI and coding staff on MS-DRG and APR-DRG payment methodologies as well as coding guidelines and regulatory requirements governing queries. Exemplifies the mission, vision and values of MedStar Georgetown University Hospital (MGUH)and acts in accordance with MGUH policies and procedures


Primary Duties and Responsibilities

Evaluates- concurrently and retrospectively- inpatient medical records reviewed by CDS for completeness, accuracy to validate that the clinical documentation supports the assigned ICD-10-CM/PCS codes, the selection of the principal diagnosis and discharge disposition following CMS requirements and Coding Clinic guidanceConducts second level reviews for MGUH approved CDI/HIM work queues and identifies missed query opportunities on conditions necessitating additional clarification within the medical record. This includes quality indicators and risk adjustment conditions.Audits work product and query compliance by CDS staff using a standard tool.Provides education to CDS based on audit results regarding query compliance, opportunities for diagnosis clarification and accuracy to improve documentation integrity.Serves as a resource to the CDS staff and ensures adherence to official coding guidelines.Utilizes data analytics and algorithms to perform prebill or post bill DRG and Clinical Validation reviews to identify revenue integrity issues and opportunities to improve quality metrics.Assists the CDI manager in maintaining work queues for bundled DRG's, mortality records and all charts deemed to require a second level review.Assists the CDI manager in educating physicians and other clinicians to facilitate documentation within the medical record to reflect the most accurate severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, and level of service renderedAssists the CDI manager with developing specific departmental goals and objectives, policies, standards and workflow procedures which directly support the strategic plan for the CDI program and MGUH.Works with other stakeholders to assist in the development and implementation of training materials related to clinical documentation, ICD-10, quality measures, and other topics as needed.Reviews and writes appeals for clinical validation external denials, as applicable, and provides feedback to the coding and CDI staff and physician advisors.Maintain a working knowledge of new coding and DRG guidelines and regulations.Assists the CDI manager in developing and maintaining reporting tools specific to productivity and quality outcomes.Assists the CDI Manager with orientation of new CDS staff and in continued professional development of experienced CDS staff.Acts as an effective liaison between the CDI and coding teams and management as required.Assumes other duties and responsibilities that are appropriate to the position and area. The above responsibilities are a general description of the level and nature of the work assigned to this classification and is not to be considered as all-inclusive.


 

Minimum Qualifications
Education

  • Bachelor's degree B.S. degree in a health care related field required

Experience

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