Lead Denial Management and Clinical Documentation Integrity (CDI) Specialist

JOB SUMMARY

Under the supervision of HIM & Professional Coding, Clinical Documentation Integrity and Denial Management Manager, the Lead Denial Management & Clinical Documentation Integrity Specialist is responsible for improving the overall quality and completeness of clinical documentation and prevent the payor denials. Review, analyze, evaluate and compose a comprehensive rebuttal via the appeal process in a timely manner to the DRG denial claims for clinical and coding denials that are received from the insurer/auditor. Work collaboratively with all members of the Memorial Healthcare team, Clinical Documentation Integrity (CDI), Coding and Revenue Cycle teams to initiate and resolve Clinical DRG and Coding disparities in dispute from the insurer/auditor. Identify patterns/trends in denial claims and recognize opportunities for enhancing optimal DRG reconciliation to prevent risk of denial. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risks of mortality, and complexity of care of the patient. Exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions or procedures. Educates members of the patient care team regarding documentation guidelines, including attending physicians, consulting physicians, allied health practitioners, nursing, and case management.

Strives for superior performance by consistently providing a product or service to leadership and staff that is recognized as ultimately contributing to the patient and family experience. Recognizes and demonstrates understanding of patient and family centered care.

PRIMARY JOB RESPONSIBILITIES
• Demonstrates knowledge of and supports hospital mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality statements, corporate compliance plan, customer service standards, and the code of ethical behavior.
• Serves as a role model, coach, resource for the CDI and Inpatient Coding teams for denial prevention opportunities during concurrent record reviews and during the coding process.
• Performs timely and accurate review of denials, appeal determination and submissions, including tracking findings and outcomes in the designated software tool.
• Remain current with regulatory/payer and internal requirements for processing/submitting appeal claims.
• Documents all appeal activity according to department standards to support accurate and timely reporting of denial and appeal status.
• Independently reviews the denial letter criteria received, reviews the medical record and pertinent documentation, laboratory values, imaging, consultant notes and any other documentation within the encounter that is relevant to the stay and uses expertise of pathophysiology, standard medical criteria for establishing diagnoses, presence of clinical support in the medical record documents for documented diagnosis, coding guidelines, and coding clinics to determine whether to appeal the denial or concur with the denial and loss of revenue.
• Effectively works both independently and as part of a team (CDI, Inpatient Coding, Revenue Cycle, Providers, etc.), often in a virtual team environment to collect and compose all pertinent information to create optimally effective appeal letters in defense of the documentation in the medical record that supports a diagnosis and supports successful outcomes.
• Provide rationale for trends/impacting factors that impact CMI and develop strategies for correcting/optimizing CMI by developing and providing education/feedback to Providers, CDI and Coding.
• Reviews CDI and Coding DRG reconciliation cases and provides final decisions on cases the CDI and Coding teams are unable to come to reconciliation on, through review of the EMR documentation and the data within the electronic business record, using coding clinics, coding guidelines, and established medical criteria to support diagnosis, being compliant with ACDIS and AHIMA guidelines.
• Identifies via review of the completed medical record during validation of insurer/payor letters of denial any opportunity for clinical and/or coding improvement or query opportunity to enhance the accuracy of documentation and clinical support of diagnoses documented in the EMR to reduce risk of denial. Denial Analyst utilizes best practices and criteria established by credible/regulatory associations (AHA, AHIMA, ACDIS, Medical Associations, CMS, etc.,)
• Follows guidelines for coding and documentation to ensure physicians and hospital compliance. Remains current with coding information to ensure accuracy of codes assigned based on documentation. Guides, supports, and sponsors concurrent clinical coding. Provides clinical interpretation of physician documentation. Acts as a liaison between the clinical and coding functions.
• Maintains professional knowledge and expertise by reading and or attending webinars/other educational venues that pertain to CDI, Coding and denial prevention.
• Provides 1:1 feedback and coaching to CDI or Coder who reviewed case regarding opportunity for improvement.
• Foster a collaborative and supportive team environment to optimize productivity and accuracy.
• As needed, assist with time & attendance, hiring, performance appraisals, disciplinary actions, training, work distribution and flow, and employee engagement.
• Performs other job-related duties as assigned.

JOB SPECIFICATIONS

EDUCATION
• Graduate from an accredited School of Nursing. BSN is required. Licensed to practice in the State of Michigan. Coding experience is strongly preferred. Demonstrated knowledge of DRG, ICD-10 coding principles or willingness to learn through approved training.
• Certified Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement Practitioner (CDIP) is required.
• Certified Coding Specialist (CCS) is strongly preferred.

EXPERIENCE
• 5+ years of clinical experience in Hospital inpatient and outpatient departments.
• 3+ years of clinical appeals/denials writing experience.
• Experience reviewing and analyzing denied/downgraded MS-DRG and APR-DRG and APC medical records and accounts received from payers (e.g., Medicare, Commercial, and Third Party).

ESSENTIAL PHYSICAL REQUIREMENTS/MOTOR SILLS
• Able to travel independently throughout all Memorial Healthcare facilities.
• Small motor skills required for operating modern computer, office, and telephone equipment as utilized by Memorial Healthcare (MHC).
• Able to sit for extended periods of time.

ESSENTIAL MENTAL ABILITIES
• Ability to adapt and maintain focus in fast paced, quickly changing or stressful situations.
• Ability to read and interpret a variety of documents including, but not limited to, policies operating instructions, white papers, regulations, rules and laws.
• Able to handle difficult and sensitive situations tactfully.
• Able to follow instructions to learn work routines and problem solve.
• Able to concentrate and maintain accuracy with frequent interruptions.
• Must be self-motivated with the ability to work independently.
• Must be able to code accurately and rapidly.
• Ability to master basic math skills.

ESSENTIAL TECHNICAL ABILITIES
• Proficiency using modern office, computer and telephone equipment as used by Memorial Healthcare.
• Motor skills required to page through hard copy and computerized records, open and close equipment, paper boxes, use typical medical office equipment.

ESSENTIAL SENSORY REQUIREMENTS
• Able to see for the purpose of reading information received in formats including but not limited to paper, computer, reports, bulletins, updates, manuals.
• Able to hear for work-related purposes.
• Ability to communicate through written and verbal communications receptively, expressively, with professionalism.

INTERPERSONAL SKILLS
• Ability to interact with co-works, hospital staff, administration, patients, physicians, the public and all internal and external customers in a professional and effective, courteous and tactful manner, at all time, physically, verbally and in all written and electronic communication.
• Required to remain calm when adversity is encountered.
• Open, honest, and tactful communication skills.
• Ability to work as a team member in all activities.
• Positive, cooperative and motived attitude.

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