Examine medical records to ensure documentation is accurate, complete, and reflective of the patient’s clinical status.
Detect inconsistencies, ambiguities, or missing information in the medical record that may impact coding, compliance, or patient care and request provider clarifications as necessary.
Verify that clinical documentation supports correct ICD-10-CM/PCS and CPT coding for proper reimbursement and collaborates with the coding/revenue cycle team.
Ensure that documentation and provider queries align with regulatory standards, including CMS guidelines and organizational policies.
Communicate and establish relationships with physicians and clinical staff to share insights, trends and education to improve documentation practices.
The Clinical Documentation Integrity (CDI) Service Line Outcomes Lead is responsible for partnering with service line & physician leadership to optimize documentation tools, improve processes, and develop strategies to reduce administrative burden on our providers, while maintaining high quality and integrity documentation.
Compensation
Base Pay Scale: Generally starting at $72.64 - $96.23 per hour
Responsibilities
Responsibility for management and optimization of the positive relationships between CDI and the service lines assigned, meeting regularly with SL Physician Champion and Chair/Chief.
Drive increased workflow efficiency through monitoring and escalating queries as appropriate.
Performance of CDI targeted audits and analysis of the findings, related to documentation and coding, to build physician education, identify areas of individual and service line opportunity, and facilitate short and long-term resolutions.
Serve as a subject matter expert and authoritative resource on interpretation and application of CDI practices, coding rules and regulations, and conducts risk assessments of potential and detected compliance deficiencies, as well as documentation opportunities within the service lines assigned.
Assists in monitoring and evaluating CDI and coding quality in relationship to best practices, while completing project-related reviews and providing relevant feedback to peers, coding, CDI leadership and quality partners, as necessary.
Reviews clinical documentation, makes judgments regarding the completeness and quality of that documentation, and facilitates modifications to clinical documentation through communication with physicians, practitioners, and medical records coding staff.
Compensation
Pay Range Minimum: $126,000.00 annual
Pay Range Maximum: $172,272.00 annual
Responsibilities
Reviews clinical documentation
Makes judgments regarding completeness and quality
Facilitates modifications to documentation
Verifies accuracy and completeness of clinical information
