SUMMARY:

Works with physicians, HIM (Health Information Management), Clinical Documentation Integrity (CDI) team members, ancillary staff, and multidisciplinary team members to improve the quality, and completeness of documentation of the patient's clinical condition and treatment provided for designated populations. Provides second-level reviews of clinical documentation of concurrent and retrospective documentation as it relates to Patient Safety Indicators (PSI), Hospital Acquired Conditions (HAC), payer denials, working DRG and final DRG mismatches, mortality reviews, and other appropriate second-levels. The second-level reviews will validate the working and/or final DRG to ensure the appropriate assignment of SOI (Severity of Illness), ROM (Risk of Mortality), and DRG (Diagnostic Related Group) assignment. Clarifies documentation by querying the medical provider via electronic or verbal communication. Collect data and produce reports as requested.

ESSENTIAL FUNCTIONS:
• Identifies patients meeting criteria for review and provides timely reviews of the clinical records.
• Reviews medical records to validate the principal diagnosis and working DRG.
• Collaborates and communicates with physicians and other medical providers, HIM (Health Information Management), Interdisciplinary Team, and ancillary staff.
• Documents in a clear, complete, concise, and organized manner using EPIC and 3M/Solventum software.
• Reviews and monitors cases identified with a Patient Safety Indicator.
• Reviews and monitors cases identified with a Hospital Acquired Condition.
• Reviews and monitors cases identified with a Patient Safety Indicator.
• Reviews cases of patients that may have expired as an inpatient.
• Reviews cases of patients identified for denial of payment by the payer for service provided by TMC.
• Collaborates with Denial Management team throughout the appeal processes.
• Reviews cases of patients that may have a mismatch of the working DRG and final coded DRG.
• Perform second-level review as directed by the RN CDI manager.
• Coordinates and collaborates with HIM/Coders and CDI RN via direct written and verbal communication to resolve issues identified in the second-level review performed.
• Participate and contribute to CDI meetings, CDI/Coder meeting, and other meetings relating expertise gathered in second-level reviews.
• Provide training to the CDI, Coding staff, and leadership on updates to quality guidelines, and denial trends.
• Analyzes current data, operations, policies, systems, procedures, and develops and implements necessary and innovative changes.
• Participates in ongoing professional development to stay current with changes in the industry as required.
• Exhibits excellence in customer service through professional attitude and interaction with providers and staff.
• Exemplifies and encourages TMCH values of integrity, community, compassion, and dedication within the workgroup and in the wider organization.
• Adheres to TMC organizational and department-specific safety, confidentiality, values policies and standards.
• Assists with program planning, development, education, and evaluation.
• Participates and encourage ongoing provider, staff, and colleague continuing education regarding changes in coding guidelines, documentation needs, and quality indicators inclusions.
• Assists in promoting quality care by identifying and referring all potential quality/compliance issues to the appropriate department.
• Promote and maintain the code of ethics established by the Association of Clinical Documentation Improvement Specialist (ACDIS) and American Health Information Management Association (AHIMA).
• Performs related duties as assigned.

MINIMUM QUALIFICATIONS

EDUCATION:
• Graduation from a qualified, nationally-accredited nursing program.

EXPERIENCE:
• Three (3) years of Medical/Surgical nursing experience in an acute hospital setting.
• CDI experience preferred.

LICENSURE OR CERTIFICATION:
• Current RN licensure permitting work in state of Arizona.
• Professional certification: CCDS (Certified Clinical Documentation Specialist) from ACDIS or CDIP (Certified Documentation Improvement Practitioner) from AHIMA preferred.

KNOWLEDGE, SKILLS AND ABILITIES:
• Strong working knowledge of all areas of adult medicine, anatomy and physiology as it relates to the acute hospital setting.
• Excellent verbal and written communication skills. Ability to communicate in a clear and concise manner with physicians and staff to ensure accurate documentation in the medical record.
• Requires critical/analytical thinking and problem solving skills in evaluating the clinical documentation.
• Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
• Ability to write reports, business correspondence, and procedure manuals.
• Ability to effectively present information and respond to inquiries or complaints from physicians and ancillary staff in a positive, professional interpersonal manner.
• Ability to calculate figures and compute rate, ratio, and percent and to draw and interpret bar graphs and apply basic algebraic concepts.
• Ability to define problems, collect data, establish facts, and draw valid conclusions.
• Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
• Understanding of Revenue Cycle including admission, billing, payments and denials.