POSITION SUMMARY: The Clinical Documentation Integrity Specialist (CDIS) will support the efforts of the VP of Quality Control & Risk Management by providing expert-level monitoring and reporting for the overall improvement and integrity of clinical documentation and utilization review monitoring. The CDIS will accomplish this by providing a proficient review and assessment of clinical documentation and risk-related cases to ensure quality metric outcomes are met as designed by value-based contract requirements. The CDIS will effectively articulate recommendations for improvement through a clinical knowledge of client care requirements, collection of aggregate data, and communication through the Quality Utilization Review (QUR) Committee.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Assists in the evaluation of the completeness of documentation of all professionals documenting in the client's electronic health record via concurrent review.
• Ensures the client record explicitly identifies all clinical findings and conditions present at the time of service and completely reflects the clinical treatment, decisions, and diagnoses for the client.
• Collaborates with the VP of Quality Control & Risk Management at the time of any findings that deviate from the standard of care.
• Identifies opportunities for improvement in the documentation that would ensure medical necessity requirements are met.
• Collaborates with providers and other organization team leaders to make improvements that result in accurate, comprehensive documentation that reflects the clinical treatment decisions and appropriate diagnosis documentation completely.
• Provides follow-through on all requests for clarification or recommendations for improvement.
• Leads the development and execution of provider education strategies that would result in improved clinical documentation.
• Proactively collaborates with coding specialists to reconcile issues related to coding and clinical documentation.
• Audits groups and treatment team meetings to ensure the care provided correlates with the documentation noted in the electronic health record.
• Supports the compliance model by tracking, cataloging, and maintaining records of findings associated with documentation and audits and reports the level of compliance in the appropriate venue.
• Utilizes appropriate software tools to ensure the tracking and reporting is aggregated into a compliance report for the quality department.
• Uses clinical expertise and clinical documentation improvement practices to ensure best practice is well established and integrated into the care, treatment, and services provided to the client.
• Ensure documentation maintains the core values and reflects the integrity of the organization.
• Ensures revenue integrity by review of the records and transparency of the operation’s revenue capture, trending, and compliance which will result in more accurate coding.
• Assist with the creation and implementation of policies and information relevant to the functioning and success of the quality and integrity of the organization’s documentation.
• Maintain confidentiality and comply with HIPAA laws.
• The Clinical Documentation Integrity Specialist is expected to protect the privacy of all persons served/client information in accordance with Addiction Recovery Care, LLC’s/Odyssey, Inc.’s privacy policies, procedures, and practices as required by federal and state law, and in accordance with the general principle of professionalism as a member of the quality and risk management team. Failure to comply with Addiction Recovery Care, LLC’s/Odyssey, Inc.’s policies and procedures on persons served/client privacy may result in disciplinary action up to and including termination of employment.
• The CDIS may access protected health information (PHI) and other persons served/client information only to the extent that is necessary to complete applicable job duties.
• Expected to report, without the threat of retaliation, any concerns regarding Addiction Recovery Care LLC’s/Odyssey, Inc.’s policies and procedures on persons served/client privacy and any observed practices in violation of the policy to their supervisor.
• Performs other duties as assigned.

EDUCATION/EXPERIENCE/CERTIFICATION:

• Bachelor’s Degree in a related field of study or 3 + years of relevant experience required.
• Ability to read clinical documentation and regulatory guidance and extract relevant and actionable conclusions.
• Excellent communication skills, both verbal and written and the ability to share complex concepts with a mixed audience in a productive manner.

  WORKPLACE ENVIRONMENT AND ESSENTIAL PHYSICAL REQUIREMENTS

• Ability to sit and/or stand for long periods of time
• Ability to read detailed health records
• Ability to lift and carry up to 10 lbs.
• Ability to operate a computer and other equipment in the office
• Must have sufficient mobility to move around the office and the community
• Attention to detail and organization a must
• Strict adherence to confidentiality requirements as outlined in 42 CFR, Part 2.
• Computer literate with experience in both Windows and Google Drive
• Ability to work independently with minimal supervision
• Ability to effectively prioritize work- and work-related responsibilities

Addiction Recovery Care, LLC offers a competitive benefits package, including:

• Health, Dental and Vision Insurance
• Optional company-sponsored retirement plan (401k)
• Short-Term/Long-Term Disability Insurance
• Other ancillary insurance products i.e., Critical Illness, Accident policies, etc.
• Paid Holidays and Vacation

Addiction Recovery Care, LLC is an equal-opportunity employer.

b1UQi3Mdaz