Clinical Documentation Integrity Quality and Outcomes Specialist

Job Profile Summary

This role focuses on activities related to revenue cycle operations such as billing, collections, and payment processing. In addition, this role focuses on performing the following CDI related duties: Facilitates improvement in overall quality, completeness, and accuracy of medical record documentation, obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and coding staff to ensure that documentation reflects the level of service rendered to patients is complete and accurate, and serves as a resource to all team members on documentation guidelines, provides guidance and support as well as assisting in the education and training related to improving clinical documentation. A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs. The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. A senior level role that requires advanced knowledge of job area typically obtained through advanced education and work experience. Typically responsible for: managing projects / processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, resolving difficult and sometimes complex problems.

Job Overview

The position focuses on activities related to revenue cycle operations such as billing, collections, and payment processing. In addition, this role focuses on performing the following CDI related duties: Facilitates improvement in overall quality, completeness, and accuracy of medical record documentation, obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and coding staff to ensure that documentation reflects the level of service rendered to patients is complete and accurate, and serves as a resource to all team members on documentation guidelines, provides guidance and support as well as assisting in the education and training related to improving clinical documentation. This role functions as a subject matter expert performing advanced second-level clinical reviews with a focus on mortality, observed-to-expected (O/E) performance, and quality outcomes.

Job Description

Minimum Qualifications:

1. Master's degree in nursing, Healthcare Management, Healthcare Administration, Business Administration, or other related field

2. Active Registered Nurse (RN) license in Massachusetts or eligible compact state within the US.

3. Seven (7) years' experience in Clinical Documentation Improvement/Integrity

4. Five (5) years' experience in an acute-care hospital setting (ICU, ED, Critical Care, strong Med/Surg Specialty) or equivalent case management, utilization review, denials management, or progressive leadership in an acute-care hospital setting

5. One (1) year Vizient experience

6. CCDS and/or CDIP Certification

Preferred Qualifications:

1. CCS Certification

2. EPIC EMR Experience

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

1. Demonstrates advanced knowledge of Official Guidelines for Coding and Reporting, APR-DRG and MS-DRG Classification System to ensure industry best practice standards and regulatory compliance related to the CDI and coding functions.

2. Demonstrates a strong understanding of case mix index, MCC/CC capture, severity of illness/risk of mortality, LOS, risk adjustment diagnoses.

3. Analyzes and interprets clinical data to identify gaps, inconsistencies, and/or opportunities for improvement in the clinical documentation and queries the provider using concurrent query process following ACDIS/AHIMA Guidelines for Compliant Query Writing.

4. Performs retrospective review of discharged encounters, accurately identifies discrepancies in documentation, and facilitates timeliness of appropriate documentation or coding modifications.

5. Completes comprehensive, clinical secondary reviews of targeted patient populations to include cases with DRG and/or code discrepancies; mortality and O/E reviews to ensure documentation accurately reflects severity of illness and risk of mortality; hospital acquired conditions (HACs), patient safety indicators (PSIs) or other top priority diagnosis as identified by Tufts Medicine for potential missed opportunities to clarify documentation or clinically validate a diagnosis.

6. Communicates findings of secondary reviews to Clinical Documentation Specialists for follow-up and query initiation while serving as a resource and mentor to concurrent CDS team members, including real time feedback on review opportunities

7. Provides targeted education and feedback to medical providers, including CMOs, hospitalists, intensivists, and other clinical leaders as it relates to documentation quality, mortality performance, and risk adjustment.

8. At leadership request, performs audit reviews of second level review work to identify educational opportunities and support quality improvement for CDI Staff.

9. Maintains clinical expertise and trends in healthcare, reimbursement methodologies and specialty areas by participating in professional organizations, seminars, and educational programs

10. Attends scheduled meetings and continuing education programs.

11. Actively encourages collaboration and possesses excellent interpersonal skills in building and maintaining crucial relationships.

Physical Requirements:

1. Professional office environment with typical office requirements such as computers, phones, photocopiers, filing cabinets, etc.

2. This is largely a sedentary role, which involves sitting most of the time, but may involve movements such as walking, standing, reaching, ascending / descending stairs, and operate office equipment.

3. Frequently required to speak, hear, communicate, and exchange information.

4. Able to see and read computer displays, read fine print, and/or normal type size print and distinguish letters, numbers, and symbols.

5. Occasionally lift and/or move up to 25 pounds.

Skills & Abilities:

1. Ability to read and write in the English language. Ability to understand and speak English fluently enough to be easily understood by patients, hospital personnel, physicians, and visitors.

2. Strong critical thinking skills and sound clinical background with a working knowledge of disease processes, anatomy and physiology, and treatment regimens.

3. Ability to analyze and interpret clinical information in the patient's medical record.

4. Excellent verbal and written communication skills with strong attention to detail and accuracy.

5. Aptitude to interact confidently and communicate effectively with physicians and other members of the clinical team.

6. Knowledge of ICD-10, AHIMA and Coding Guidelines, healthcare regulations, reimbursement, and documentation requirements.

7. Willingness to work collaboratively within a team.

8. Open, flexible, and adaptable to a changing environment as the CDI industry continues to change and evolve.

9. High level Computer literacy and efficiency with technology, including but not limited to, Microsoft Office Suite (including Word, Excel, Teams), Zoom, Epic, 3M360.

10. Ability to use good judgment in an emergency situation.

11. Commitment to upholding and providing services in a manner that is congruent with the Hospital's mission statement.

At Tufts Medicine, we want every individual to feel valued for the skills and experience they bring. Our compensation philosophy is designed to offer fair, competitive pay that attracts, retains, and motivates highly talented individuals, while rewarding the important work you do every day.

The base pay ranges reflect the minimum qualifications for the role. Individual offers are determined using a comprehensive approach that considers relevant experience, certifications, education, skills, and internal equity to ensure compensation is fair, consistent, and aligned with our business goals.

Beyond base pay, Tufts Medicine provides a comprehensive Total Rewards package that supports your health, financial security, and career growth-one of the many ways we invest in you so you can thrive both at work and outside of it.

Pay Range: