Under general supervision of the Director of Clinical Documentation Integrity and in some situations the supervision of the Clinical Documentation Integrity Manager, and in collaboration with physicians, nursing and HIM coders, the Clinical Documentation Quality Liaison strategically facilitates and obtains appropriate and quality physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. The Clinical Documentation Quality Liaison educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, care management and quality abstracters. The Clinical Documentation Quality Liaison provides timely review and response to Iodine Retrospect Cases. Tracking and trending patterns for areas of opportunity CDI education. The Clinical Documentation Quality Liaison adheres to strict departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality documentation and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
The value you’ll bring to the team
- Demonstrates, thoughtful behavior, Integrity, Compassion, Balance, Excellence, Stewardship, and Teamwork
- Reviews mortality reviews to ensure the ROI/SOM scores are appropriate and consistent in documentation of care delivered.
- Completes accurate and timely record review to ensure the integrity of documentation compliance. Completes accurate and concise input of data into Iodine resulting in accurate metrics provided by the CDI program. Understands and supports CDI documentation strategies (upon completion of training) and continues to educate self and team members using educational tools, videos and provided WebEx’s.
- Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision making keeping reimbursement considerations in balance with regulatory compliance. Initiates/formulates CDI severity worksheets and clinically credible clarifications for inpatients, sending/presenting opportunities for improved documentation compliance to physicians, nurse practitioners and other medical staff.
- Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs and HACs to ensure documentation compliance is accomplished.
- Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including attending physicians, allied health practitioners, nursing, and care management. This includes quarterly compliance updates from Medicare.
- Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation. Communicates with HIM staff and collaborates with them to resolves discrepancies with DRG assignments and other coding issues.
- Completes well-timed follow-up case reviews on all concurrent cases with priority given for resolution of those with clinical documentation clarifications
- Participates in Task Force meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified by the CDI group.
- Reviews and responds to clinical validation denials to ensure compliance with Clinical Documentation Integrity guidelines.
- Tracks and trends denials to provide education and feedback to CDI teams on areas of concurrent documentation improvement.
- Assumes personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency.
- Performs other duties as assigned.
The expertise and experiences you’ll need to succeed:
Education and experience required
- Nursing degree (RN, BS, BSN, or advanced degree)
- Five years of acute clinical experience
- Experience in Clinical Documentation Improvement and Acute Care
- Experience with Microsoft Office (Excel, PowerPoint, and Word)
Education and experience preferred
- Master’s degree in Nursing or related health care related field
- Experience educating in a healthcare or Clinical Documentation Improvement setting
- Coding background
Licensure, Certification or Registration required
- Current valid State of Florida or multi state license as a Registered Nurse
Licensure, Certification or Registration Preferred
- CCDS (Certified Clinical Documentation Specialist) certification through ACDIS (Association of Clinical Documentation Improvement Specialist) or CDIP (Certified Documentation Improvement Practitioner) certification through AHIMA (American Health Information Management)