Clinical Documentation Integrity Specialist-Coding

Job Description

The CDI primary role will be auditing inpatient/ outpatient cases for DRG validation and/or documentation improvement opportunities utilizing a unique approach that combines technology, coding and clinical documentation auditing expertise. Responsibilities include working directly with the Physicians, Coders and CDI team members to streamline processes, identify training needs and ensure consistent information is shared. Provide training, as needed to ensure quality and productivity standards are met. This person should have strong coding skills, extensive knowledge of medical terminology, the human disease process, and anatomy & physiology, along with a thorough understanding of the workflow and processes utilized by the team members to successfully complete review processes. Viewed as an expert, highly sought-after resource, and a key advisor to other business partners. Ensures compliance of coding/billing and charging with regulatory and accreditation standards.

Responsibilities

• Prepares medical records in the inpatient and/or outpatient setting to capture an accurate representation of the severity of illness and facilitate proper coding.
• Improves documentation practices to reflect quality and outcome scores.
• Develops and educate physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record;
• Obtains and promote appropriate clinical documentation through extensive interaction with physicians to ensure that the documentation of the level of service rendered to the patient and the patient's clinical complexity is complete and accurate;
• Performs remote and on-site paper or electronic medical chart review and clinical validation audits and interpretation of medical documentation to ensure clinical support of all relevant coding based on AHIMA guidelines;
• Facilitates and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient
• Assess review data to determine areas of improvement for follow up physician training and communication
• Utilizes query process when code assignments are not straightforward or documentation is not clear for coding purposes;
• Maintains Clinician focused process design, data analysis, and improvement strategies to drive project execution for high quality/high priority outcomes;
• Assess clinical aspects of medical record documentation to drive improvement and consistency in application across Medical Group adult primary care and specialty clinics.
• Prepares spreadsheets to collect and support chart review findings;
• Recommends necessary training to correct deficiencies for the department/section
• Communicates effectively all relevant policies and procedures, of the facility to the current and prospective employees
• Contributes to the processes used in the performance of the CDS role, through SOP development and revision, and process improvement
• Responsible for providing accurate information to the management, finance leadership, and medical team.
• Contributes to the processes used in the performance of the CDS role, through SOP development and revision, and process improvement
  
  

Accountabilities

• Maintains patient medical records in the inpatient and/or outpatient setting to capture an accurate representation of the severity of illness and facilitate proper coding.
• Determines and validates that coding reflects medical necessity of services and facilitates appropriate coding which provides an accurate reflection and reporting of the severity of the patient’s illness along with expected risk of mortality and complexity of care.
  
  

Qualifications

Experience :-

Required

• Experience in IR-DRG, ICD10 and CPT
• Experience with Statistical analysis/ Data Analysis
• Experience with Microsoft Office Tools
• Experience in a large healthcare facility
  
  

Desired

• Experience in a large healthcare facility
• Experience in IR-DRG and ICD10
  
  

Educational Qualification: Required:

• Any of the following: Registered Health Information Technician (RHIT), Certified Coding
  
  

About Us

At SSMC, we firmly believe that the human touch is a fundamental part of care. We understand that health care is both an art and a science, running deeper than simply diagnosing and treating those who rely on us. Our SSMC Model of Care puts our patients at the forefront of our purpose and at the heart of everything we do, ensuring that the needs of our patients come first. Every one of our patients receives individualized attention from a multidisciplinary team of experts who collaborate closely to deliver trusted and compassionate care. From the very first point of contact with SSMC, to the moment patients are back home, we ensure speciality-specific care at every stage and in every interaction. As one of the largest tertiary hospitals in the UAE, SSMC provides access to specialist medical treatments and advanced diagnostics, with a commitment to becoming a Destination Medical Center in the UAE and wider region.

About The Team

About Sheikh Shakhbout Medical City (SSMC)

SSMC is the largest tertiary hospital in the UAE and serves to elevate the provision of health care services in the nation under the mandate of the Abu Dhabi Economic Vision 2030.

Supported by the latest diagnostic and treatment modalities available, SSMC offers care in 44 specialties. A team of locally and internationally trained medical, clinical and admin professionals work seamlessly together, which promotes comprehensive interdisciplinary learning, allowing SSMC to become a leading hub for integrated patient-centric medical services in the region.

As the region’s leading tertiary facility, SSMC has 742 patient beds, 18 operating theatres, and includes a hybrid operating room, 26-bed neonatal intensive care unit, and the UAE’s largest pathology lab.