Job Summary

This Clinical Documentation Integrity Specialist III (CDIS III) position is fully remote and will include Team lead role and second level reviewer. These roles are pivotal in enhancing the quality and completeness of provider-based clinical documentation within inpatient medical records. 

CDIS III - Team Lead; serves as a key resource for CDI/Coding/Quality, and works in collaboration with CDI & quality leadership, CDI specialists, coders, quality analysts, providers, and other members of the healthcare team to ensure accurate, high-quality clinical documentation to support Michigan Medicine initiatives. Performs high-level, complex, primary and secondary case reviews to facilitate and obtain appropriate provider documentation for clinical conditions or procedures to reflect the severity of illness, expected risk of mortality, accuracy of patient outcomes, and complexity of patient care. 

CDIS III - Second Level Reviewer; performs high-level, complex, secondary case reviews to facilitate and obtain appropriate provider documentation for clinical conditions or procedures to reflect severity of illness, expected risk of mortality, accuracy of patient outcomes, PSI90/HAC reviews, clinical denials and appeals and complexity of patient care. Serves as key resource for CDI/Coding/Quality. The CDI Second Level Reviewer works in collaboration with CDI & quality leadership, CDI specialists, coders, quality analysts, providers, and other members of the healthcare team to ensure accurate, high-quality clinical documentation to support Michigan Medicine initiatives.

Responsible for facilitating accurate representation of a patient's clinical status that affects present on admission (POA), severity of illness (SOI), risk of mortality (ROM) scores, as well as hospital reimbursement and the level of services provided. Collaborate with physicians and other clinical staff to ensure comprehensive documentation that supports the correct coding assignments at the time of discharge. The role includes the development and implementation of an education plan targeted at providers, which will convey the principles of precise and complete documentation. This plan will also highlight the impact that documentation has on SOI, ROM, and length of stay (LOS). 

Mission Statement

Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally.  Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.

Responsibilities*

TEAM LEAD:

• Perform initial reviews of inpatient records to clinically evaluate any opportunity to clarify with the clinician additional diagnoses and/or procedures that impact (this is not an exhaustive list) DRG assignment, PSI, HAC, SOI, ROM, POA and Risk O:E., risk adjustment and code assignment for accurate billing.
• Perform subsequent/follow-up reviews.
• In collaboration with Leadership & CDI Coordinator; conducts new-hire training/orientation.
• Precepts new CDIS staff
• Support staff as the first-line key resource for CDIS staff. 
• Serves as an escalation point for CDI, coding, and/or quality discrepancies (i.e., DRG mismatch, missing query response, code change, etc.).
• Performs audits on CDIS to ensure quality and compliance.
• In collaboration with leadership & CDI Coordinator, analyze data to determine areas of focus and specific education needs.
• Identifies knowledge gaps and provides tactful, clear explanations and rationales supported by industry standard guidance.
• Provides coaching and increased oversight for staff needing remediation, ensuring effective team building and conflict resolution.
• Monitor daily productivity and workflows processes, proactively intervening when necessary.
• Ensure that monthly key metrics are met and provide coaching as needed. This is accomplished through data evaluation, direct observation, review of medical records and daily staff communication.
• Perform duties and conduct interpersonal relationships in a manner that promotes a team approach and collaborative work environment with physicians, CDI staff, quality analysts, and coders.
• Collaborate with CDI Manager/Director and Physician Champions/Advisor regarding any physician engagement concerns and action plan recommendations.
• Assists with ad-hoc projects and other duties as deemed necessary by CDI Manager(s) and/or Director.
• Utilize the provided CDI software to determine appropriate DRG, SOI, ROM, Risk and POA assignment.
• Evaluate clinical documentation such as signs, symptoms, lab results, diagnostic information and treatment plans to determine documentation improvement opportunities and appropriately clarify with providers.
• Initiate communication with clinicians through the formal query process.
• Prepare case-specific documentation examples and PowerPoint presentations to be given to clinical treatment teams and departments as it relates to documentation and the EHR.
• Develops and conducts ongoing education for new staff, including new CDI Specialists, physicians, and nursing.
• Follow the guidance of the HIM Coding-CDI Query Policy
• Follow the guidance of the Query escalation policy and the Standards of practice for quality and production/productivity.
• Requires proficiency in abstracting and data entry into all databases used for CDI.
• Participate in and demonstrate an understanding of the Michigan Medicine annual SMART goal/evaluation process & CORE values.
• Demonstrate initiative by continuous expansion of knowledge and skills.
• Participate in department/unit activities including, but not limited to staff meetings, in-services, workgroups & trial groups.
• Involvement in third party audit denials and appeal processes, including but not limited to reviewing denials and submitting supporting documentation/evidence for defense. 
• Perform other duties as assigned to maintain the efficiency of the department.

SECOND LEVEL REVIEWER:

• Performs high-level, complex, timely secondary case reviews concurrently and retrospectively to identify potential gaps or opportunities to facilitate improved provider documentation.
• Ensure clinical documentation accurately reflects the level of care rendered, severity of illness, risk of mortality, and clinical validation (in compliance with government and other regulations).
• Applies advanced knowledge of CMS star rating, Vizient, and US News and World Report risk-adjustment systems to identify clinical documentation improvement opportunities.
• Completes quality reviews focused on CDI quality elements, such as Mortality, Hospital Acquired Conditions (HAC), and other publicly reported patient quality or safety metrics (i.e. AHRQ Patient Safety Indicators).
• Identify trends and key areas for improvement in querying, coding, and documentation integrity.
• Makes recommendation of possible refinement of principal diagnosis, secondary diagnoses, and/or procedures based on clinical data to facilitate appropriate DRG assignment.
• Records review findings and other data elements accurately into CDI Software and other data mechanisms to support data integrity for reporting.
• Effectively and appropriately communicates and collaborates with providers, HIM/coding, quality, CDI, and other members of the healthcare team.
• Assists with concurrent and retrospective CDI case reviews, quality audits, and education as deemed necessary by CDI Leadership.
• Participates in meetings, including providing feedback and identifying trends and opportunities, presentations for educational opportunities, and any other needs identified by the CDI leaders.
• Utilize the provided CDI software to determine appropriate DRG, SOI, ROM, Risk and POA assignment.
• Evaluate clinical documentation such as signs, symptoms, lab results, diagnostic information and treatment plans to determine documentation improvement opportunities and appropriately clarify with providers.
• Initiate communication with clinicians through the formal query process.
• Prepare case-specific documentation examples and PowerPoint presentations to be given to clinical treatment teams and departments as it relates to documentation and the EHR.
• Develops and conducts ongoing education for new staff, including new CDI Specialists, physicians, and nursing.
• Follow the guidance of the HIM Coding-CDI Query Policy
• Follow the guidance of the Query escalation policy and the Standards of practice for quality and production/productivity.
• Requires proficiency in abstracting and data entry into all databases used for CDI.
• Participate in and demonstrate an understanding of the Michigan Medicine annual SMART goal/evaluation process & CORE values.
• Demonstrate initiative by continuous expansion of knowledge and skills.
• Participate in department/unit activities including, but not limited to staff meetings, in-services, workgroups & trial groups.
• Involvement in third party audit denials and appeal processes, including but not limited to reviewing denials and submitting supporting documentation/evidence for defense.
• Perform other duties as assigned to maintain the efficiency of the department.

Required Qualifications*

• A bachelor?s degree (or the equivalent education and experience) in health information technology and registration with the American Health Information Management Association as a RHIT or RHIA and or certification as an RN, or a bachelor?s degree and certification in Nursing and or NP, PA or MD.
• 3-5 years of CDI experience working with coded data associated with clinical documentation 
• Two years in the role of CDIS at Michigan Medicine
• Experience analyzing Vizient risk data and AHRQ quality measures
• Either CCDS or CDIP credential
• Demonstration of proficiency in productivity, communication & leadership attributes
• Adhering to the MM remote work agreement

Modes of Work

Positions that are eligible for hybrid or mobile/remote work mode are at the discretion of the hiring department. Work agreements are reviewed annually at a minimum and are subject to change at any time, and for any reason, throughout the course of employment. Learn more about the work modes.

Background Screening

Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings.  Background screenings are performed in compliance with the Fair Credit Report Act. Pre-employment drug testing applies to all selected candidates, including new or additional faculty and staff appointments, as well as transfers from other U-M campuses.

Application Deadline

Job openings are posted for a minimum of seven calendar days.  The review and selection process may begin as early as the eighth day after posting. This opening may be removed from posting boards and filled anytime after the minimum posting period has ended.

U-M EEO/AA Statement

The University of Michigan is an equal opportunity/affirmative action employer.