Clinical Documentation Integrity Specialist I (Relief, Non-benefitted)

About this role

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Day - 08 Hour (United States of America)

This is a Stanford Health Care job.

A Brief Overview The Relief Clinical Documentation Integrity Specialist I uses clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of inpatient and/or outpatient medical records to evaluate the clinical documentation of clinical services by identifying opportunities for improving the quality of medical record documentation. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate communication, severity of illness, expected risk of mortality, and complexity of care of the patient. A successful Relief Clinical Documentation Integrity Specialist I will be adept in clinical experience and knowledge, understanding documentation and coding guidelines, recognizing gaps and issues, as well as the impact of documentation and coding on the patients, the providers, the hospital and related outcomes.

This is an entry level, trainee and contributing level. Entry-level professional with limited or no prior experience; learns to use professional concepts to resolve problems of limited scope and complexity; works on developmental assignments that are initially routine in nature, requiring limited judgment and decision making. Performs the more routine CDI work and in a learning capacity, assists in the technical review of various types of medical records within expanding scope of clinical specialty and some exposure to additional complexity, as well as exposure to other projects. Requires basic clinical, coding and/or CDI knowledge and understanding of the theories, concepts, principles and practices of medical record documentation and/or data analysis. Learns to apply professional principles, theories, and concepts through work assignments. Works on problems of limited scope; routine in nature. Follows standard practices and procedures in analyzing situations or data from which answers can be readily obtained. Close monitoring and partnership with preceptors/more experienced Clinical Documentation Integrity Specialists. Works under close supervision.

Assignments are designed to provide training and practical experience that develops the incumbent's ability to apply CDI and coding principles, methodologies, and procedures. Decisions are limited to specific, task-related activities. Requires the manager's, Lead's or preceptor's review of the work performed, while in progress and at its completion, for accuracy, completeness, and conformance with detailed instructions. Work is primarily with existing, stable processes and procedures. As the employee's skill level progresses, close supervision is relaxed. Supervised and limited client interaction. As the employee's skill level progresses, supervision of limited interaction is relaxed.

Locations Stanford Health Care

What you will do • Documentation and Coding Analysis:

• Reviews clinical documentation to facilitate the accurate representation of the severity of illness, expected risk of mortality, and complexity of care by improving the quality of the physician’s clinical documentation.

• Initiates medical record review within 24 to 48 hours of admission. Monitors, systematically, the targeted medical records within at least 48 hours unless otherwise indicated) to determine compliance to established documentation standards. Conducts follow-up reviews to ensure points of clarification have been addressed/documented in the medical record.

• Utilizes Hospital coding code set, policies and procedures, Federal and State coding reimbursement guidelines, and application of the Coding Clinic Guidelines to assign working DRG, reviewing patient records throughout hospitalization that have been identified as focus DRG by regulatory agencies or the facility to ensure the codes are reported at the highest specificity.

• Partners with the Inpatient coding staff to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, risk of mortality and quality outcomes.

• Advises and counsels clinical providers in assigned areas in clinical documentation and coding concepts, query procedures and processes.

• Responsible for units and/or service lines assigned by manager.

• Maintains liaison with department or service line clinical providers in documentation Integrity strategies, opportunities and specific clarification requests.

• Suggests improvements to enhance documentation Integrity or clinical provider documentation process.

• Documentation Integrity Strategies and Provider Partnership:

• Contributes to provider engagement, relationship establishment and maintenance related to CDI and documentation Integrity efforts, with all providers through the query process.

• Addresses abnormal ancillary test findings when they occur and query physicians on a current basis to include face-to-face interactions regarding the impact on patient care and DRG assignment.

• Initiates physician interaction when ambiguous, missing or conflicting information is in the medical record, through the physician query process and/or participation in rounding with the physicians by requesting additional documentation for correct coding and compliance necessary for accurate reflection of CMI, LOS, and optimal resource utilization.

• Assists CDI service line teams and leadership in the ongoing evaluation of clinical documentation and potential improvement initiatives.

• Documentation Performance, Reporting and Enhancements:

• Performs ongoing documentation analysis for assigned units and/or service lines and submits documentation clarifications or queries to mitigate gaps or inconsistency in documentation, thus ensu

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