Description

CLINICAL DOCUMENTATION INTEGRITY (CDI) AUDITOR

SUMMARY

The Clinical Documentation Integrity (CDI) Auditor is responsible for the overall quality, completeness, and accuracy of the medical record documentation through extensive audit review, clinical criteria research, drafting of appeals, and data trending. Internal auditing for the CDI program will ensure compliance, quality, denial trends, and educational opportunities are identified and solved in partnership with CDI leadership. Responsible for the review, appeal, and tracking of DRG denials received through government audits and/or commercial payers. Strong aptitude for quickly troubleshooting and identifying the cause of questionable results within abstracts and reports.  Works in association with the CDI staff, clinicians, coders, and all members of the healthcare team to ensure accurate and timely clinical documentation in the medical record.

POPULATION SPECIFIC CARE

No direct patient care.

ESSENTIAL FUNCTIONS

An employee in this position may be called upon to do any or all of the following essential functions. These examples do not include all of the functions which the employee may be expected to perform.  

        Manages the DRG denial and appeal process for CDI. Reviews DRG denial cases received from government audits and/or commercial payers.  Research case content and denial rationale. Draft appeal letters with relevant citations from the clinical chart and appropriate clinical references to support argument. Ensure timely submission of appeals through the appropriate workflows.

        Track volumes, trends, outcomes, and other pertinent data elements needed to measure the success and/or identify continued risk to the organization for future denials and recoupment of funds.

        Collaborates with CDI Manager and CDI Educator to review trends related to denials, query activity, and revenue cycle opportunities to inform educational content and strategic planning for CDI, HIM Coding, or Provider audiences. Develops and delivers educational materials and presentations to individuals and/or group settings.

        Develops library of appeal templates to streamline efficiency of the denial review and appeal process. 

        Performs second-level audits of CDI reviews and queries to ensure compliant practice, identify educational topics, and opportunities for workflow or technology optimization. Synthesizes findings to provide recommendations to ensure CDI program growth and compliance with hospital policy, medical staff by-laws and regulatory and legal requirements, and departmental policies and procedures.

        Conducts advanced CDI chart reviews based on DRGs and care site-specific trends to identify gaps in documentation and training opportunities. Provides clinical subject matter expertise in reviewing cases identified through internal processes to appropriate stakeholders.

        Supports the coordination of internal CDI team and/or HIM departmental projects to support the organizational pillar goals and advancement of the CDI program with national best practice standards.

        Acts as a coding and clinical documentation resource for hospital based and contracted physicians.

        Maintains subject matter expertise within CDI, Coding, and Quality.

 SCOPE AND LEVEL

        Guidelines: Guidelines are generally but not always clearly applicable, requiring the employee to exercise judgment in selecting the most pertinent guideline, interpret precedents, adapt standard practices to differing situations, and recommend alternative actions in situations without precedent.

        Complexity: Duties assigned are generally complex and may be of substantial intricacy.  Work assignment is performed within an established framework under general instructions but requires simultaneous coordination of assigned functions or projects in various stages of completion.

        Decision Making: Exercises judgment and discretion, and is responsible for determining the time, place and sequence of the work performed.

        Communications: Contacts with team members, clients or the public where explanatory or interpretive information is exchanged, defended, and gathered and discretion and judgment are required within the parameters of the job function.

        Supervision Received: Performs work with minimal supervisory oversight.  Under general supervision, the employee receives assignments and is expected to carry them through to completion with substantial independence.  Work is reviewed for adherence to instructions, accuracy, completeness, and conformance to standard practice or precedent.  Recurring work clearly covered by guidelines may or may not be reviewed.

MINIMUM QUALIFICATIONS 

Education, Experience, Licensure, Certification

        EDUCATION – Associate Degree in Nursing.

        EXPERIENCE – Three (3) years of experience to include: one (1) year of experience within Clinical Documentation Integrity in the inpatient acute care setting and one (2) years of experience as a clinical nurse in an inpatient acute care setting.  

        EQUIVALENCY – None.

        CERTIFICATION(S) – Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) is required.

        LICENSURE – Active Registered Nurse licensure is required.

Requirements

Please note:  Associate Degree in Nursing (minimum education), active RN licensure, CCDS or CDIP, 3 years of experience (includes at least one year of CDI in the inpatient acute care setting AND at least two years of experience as a pediatric or neonatal nurse in an acute care setting).

The following is a list of states where team members are not allowed to work remotely for Children’s Colorado, due to employment laws and regulations, compliance requirements, taxes, and/or workers compensation: Alaska, Alabama, California, Connecticut, District of Columbia, Kentucky, Maryland, Massachusetts, Nevada, New Hampshire, New Jersey, New York, North Dakota, Ohio, Oregon, Pennsylvania, Vermont, Washington, Puerto Rico, U.S. Virgin Islands. (NOTE: Unfortunately, there are NO exceptions related to this)

PHYSICAL REQUIREMENTS

        Audio-Visual: Color Discrimination – Fair

        Audio-Visual: Depth Perception – Fair

        Audio-Visual: Near Vision: Good

        Audio-Visual: Far Vision: Good

        Audio Visual: Hearing: Good

        Motion: Bend : Up to 1/3 of the time

        Motion: Reach up to 1/3 of the time

        Motion: Carry up to 1/3 of the time

        Motion: Pull up to 1/3 of the time

        Motion: Push up to 1/3 of the time

        Weight Lifted/Force Exerted: Up to 10 lbs. or more of the time

        General Activity: Stand/Walk up to 4hrs a day

        Use of hands/feet: Precise Motion Function (or fine manipulation) 

WORK ENVIRONMENT

        Exposure: Exposure to blood/body fluid: Occasional

        Exposure: Exposure to cold/heat: Occasional

        Exposure: Exposure to infectious disease: Occasional

        Mental and Emotional Requirements:  Manages stress appropriately

        Mental and Emotional Requirements: Works with other effectively

        Mental and Emotional Requirements: Handles multiple priorities effectively.

        Mental and Emotional Requirements: Independent discretion/decision making.

        Mental and Emotional Requirements: Makes decisions under pressure.

        Mental Stress: multi-tasking, meeting deadlines, prioritizing