Job Description Summary:The Clinical Documentation Integrity (CDI) Liaison is responsible for improvement in the overall quality, completeness, and accuracy of the medical record documentation by:
- Facilitating modifications to clinical documentation via acting as a liaison between the Clinical Documentation Integrity team, Coding team, providers and other relevant parties
- Performing ongoing, quality assurance, ad hoc and special project reviews assigned for various purposes and goals requiring advanced clinical documentation improvement knowledge, ICD-10 CM and PCS coding knowledge and review skills
- Compilation and organization of review summaries performed and delivery of organized and concise presentations as requested
- Teaching key CDI-related and coding concepts
- Interpretation and translation of clinical information as it pertains to CDI and coding concepts
- Applying advanced relevant knowledge and skills to formulate recommendations and develop education as needed
- Ensuring that documentation practices and processes comply with applicable regulatory guidelines, rules and requirements
- Follows all applicable departmental and institutional policies and procedures
related to CDI/coding
- Meets performance standards by setting goals and objectives, prioritizing work and using available resources efficiently and effectively
- Remains apprise of the latest developments, official guidelines and guidance updates and trends in the CDI and coding fields via professional publications and continuing education, and integrates this knowledge into work practices
- Review records and queries physicians using the approved query process in order to obtain clinical information. Participates in the review clinical validation denials and other value measurement/financial sustainability projects. Adheres to the standards of ethical and compliant coding per AHA ICD-10-CM/PCS coding guidelines and MSKCC internal coding guidelines
- Interacts with physicians, advance practice providers, allied health practitioners, case managers, dieticians and other members of the patient care team to gather accurate and timely clinical information for abstraction into a designated CDIS database
- Performs outpatient and inpatient CDI collaboratively with inpatient and ambulatory physicians and advance practice providers in various assigned settings to ensure that clinical documentation within the medical record is accurately captured in terms of diagnosis and coding
- This includes documentation to support the capture of Hierarchical Condition Categories (HCCs), ICD-10-CM specificity and the medical necessity of ambulatory visits and/or treatments. Educates members of the patient care team both formally and informally regarding documentation guidelines, coding requirements and service specific requirements
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- Participates in the training and orientation of new CDI team members
- May perform concurrent CDI reviews when clinical documentation specialist coverage is needed
Time: 60% Documentation Improvement-
- Performing ongoing, quality assurance, ad hoc and special project reviews assigned for various purposes and goals requiring advanced clinical documentation improvement knowledge and review skills
- Regularly audits patient medical records and associated coded data as assigned to identify opportunities including but not limited to accurate DRG optimization, appropriate reflection of severity of illness, risk of mortality, length of stay and overall documentation quality
- Effectively records, summarizes, and communicates review details and findings with manager
- Ensures accuracy and integrity of the medical record abstract data prior to billing interface and claims submission. Partners with Patient Accounts and Finance staff to resolve any issues related to coding/reimbursements
- Performs clinical record abstracting and data collection to justify and support optimal reimbursement, data quality, performance improvement analysis, and outcome reporting initiatives. Assigns and sequences ICD-10-CM diagnosis and procedure codes and/or CPT codes in compliance with UHDDS, billing requirements, and organization specific policies
Time: 30%
- Assists CDI manager with ongoing quality assurance reviews of clinical documentation staff
- Monitors and validates queries for necessity, accuracy and compliance
- Contributes to feedback pertaining to clinical documentation integrity specialist staff performance and evaluation
- Serves as a departmental subject matter expert
- Serves as a resource to the CDI specialist team in resolving relevant daily issues and questions and collaborates via effective communication with the Coding team to assist with similar CDI-related questions/issues
Time: 5%
- Creates and/or delivers CDI-related education/training to providers as needed on an ad hoc basis
- Assists in relevant CDI-related education of providers, CDI staff and coders
- Performs other duties as requested related to CDI
Minimum Qualifications:Current nursing (RN) license with bachelor's degree in nursing or RN license with bachelor's degree in Health Information Management (HIM) or other related field, and/or graduate education leading to Physician Assistant (PA) with PA license, and/or graduate education leading to MD, DO or equivalent degree required. ACDIS Certified Clinical Documentation Specialist (CCDS). Experience with ICD-10 CM/PCS coding and DRG assignment. 2 years of relevant clinical documentation improvement experience. 2 years demonstrated clinical experience in the acute care setting. Excellent written and oral communication skills and excellent interpersonal skills. Microsoft Office competency, including but not limited to PowerPoint, Work and Excel.
Preferred Qualifications: Master's degree in nursing with advanced practice license and congruent experience in the acute care setting. AHIMA Certified Coding Specialist (CCS)
Working Conditions/Physical Demands:Interaction with clinical and other staff. Hybrid with expectation to come onsite only as needed to Memorial Sloan Kettering locations.tation specialist coverage is needed
Pay Range: $124,000.00 - $204,700.00
FSLA Status: Exempt
