Clinical Validation Appeals Specialist

Reporting to the MHN CDI Manager, the MHN CDI Clinical Coordinator is responsible for training of new CDI staff and continued education of the CDI team, with a focus on the CDI Processes, exercises critical thinking skills and deductive reasoning with documentation improvement. Works in conjunction with CDI Manager to conduct CDI education with all physicians and extenders as identified through documentation trends. Instructs CDI staff on proper compliant and clearly defined queries based on progress notes, consult notes, lab and radiology reports, risk factors, severity of illness and appropriate treatment modalities. Maintains and applies up-to-date knowledge of current clinical documentation practices to ensure the medical record accurately reflects patient care and ensures proper coding using MMS-DRG, APR-DRG, ICD-10 and Coding Guidelines. Participates in committees/ad-hoc meetings as needed to provide CDI expertise to improve documentation. Conducts weekly audits of the CDI chart reviews and queries, while providing feedback that encourages CDI staff productivity and improvement, coordinates with HIM/coders for accurate reconciliation of the chart, participates in physician education for clinical documentation to capture the most accurate patient profile.

Marshall Health Network System Specific Duties and Responsibilities:

• Self directs work-time and prioritizes work activities according to the current daily case load of initial, concurrent and unanswered queries
• Daily presentation and education with explanation of queries to hospital physicians and extenders
• Participates in committees/ad-hoc meetings as needed to provide CDI expertise to improve documentation
• Maintains a high degree of ethics, integrity and confidentiality of patient information, in addition to hospital and individual physician practice pattern data
• Provides information and in-services as necessary to CDI staff, physicians and extenders
• Coordinates communication among medical consultants and appropriately intervenes to clarify and specify documentation that captures an accurate patient profile for severity of illness and risk of mortality
• Coordinates with HIM/Coders and HIM Leadership
• Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment
• Adjusts and is flexible to meet changing work needs and demands
• Recognizes and care about others' accomplishments, provides feedback, while educating others
• Meets with CDI manager to analyze data and identify potential process improvement opportunities
• Communicates ideas or positions in a persuasive manner that builds support, agreement or commitment
• Creates an environment that encourages and values the opinions of others and promotes sharing of information and ideas
• Embraces achieving best practices efficiently
• Reviews coded documentation to ensure proper code assignment and send through proper billing process timely to avoid any delays in DNFC/DNFB
• Promotes compliance with CMS, Medicare documentation, third party payers, coding and billing regulations
• Works closely with CDI staff to identify areas of documentation improvement, and query templates to support accurate and complete documentation
• Educates CDS on identified knowledge gaps, at-risk DRGs, etc.; Delivers targeted education material and provides on-site education as appropriate
• Performs internal audits on CDI staff to ascertain where stronger education is needed and implements needed education
• Stays updated on CDI related literature, participates in work groups, serves as educator and mentor to CDI staff
• Ensures that CDI staff are in compliance with standards and adhering to policy; Regularly communicates education program's performance, gaps, opportunities and progress with CDI manager
• Assists with new provider onboarding sessions to provide education and training resources related to inpatient CDI as needed
• Acts in the capacity of a clinical documentation specialist as needs dictate

Qualifications:

• Current RN license.
• Minimum of 5 years of experience in clinical documentation improvement.
• Proficiency in medical coding systems (ICD-10, CPT).
• Exceptional writing and analytical skills.
• Ability to work independently and meet strict deadlines in a high-pressure environment.
• Experience with electronic health records (EHR) and Microsoft applications.

Work Environment:

This role operates in a remote or hybrid office setting with standard business hours, Monday through Friday.