Actalent
Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.
The Inpatient Clinical Documentation Integrity (ICDI) Specialist is accountable for reviewing patient medical records in the inpatient and/or outpatient setting to capture accurate representation of the severity of illness and facilitate proper coding.
High School diploma or GED required. Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Registered Nurse (RN), Registered Respiratory Therapist, Certified Coding Specialist (CCS), or Certified Coding Specialist-Physician-based (CCS-P), or International or Domestic Medical Degree also required. MUST HAVE: Experience in Trauma or Transplants, 3+ CDI experience, Large Facility (need complexity), 100% Production, very flexible and willing to adapt to a very complex environment. MUST HAVE: Certified Documentation Improvement Practitioner (CDIP) certification or Certified Clinical Documentation Specialist (CCDS) certification required. Bonus: 3M360 and Optum and Epic experience a huge plus. CCS and/or CRC are also a huge plus. DRG validation/ DRG auditor experience are also a plus. Experience Level: Intermediate Level
Validates 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. Documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care. Utilizes advanced knowledge of disease processes (pathophysiology), medications, and have critical thinking skills to analyze current documentation to identify gaps. Identifies opportunities in concurrent and retrospective inpatient clinical medical documentation to support quality and effective coding. Understands and applies regulatory compliance related to documentation, coding and billing for all health insurance plans. Facilitates appropriate modifications to documentation through extensive interactions and collaboration with physicians, coding, case management, nursing and other care givers. Serves as an effective change agent as an educator and resource for physicians and allied health staff to improve the quality and completeness of the clinical documentation. Performs all duties and responsibilities in accordance with ethical and legal business procedures, compliant with federal and state statutes and regulations, official coding rules, guidelines and accepted standards of coding practice including appropriate clinical documentation policies.
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