Job Description

Position Details

Lakeland Regional Health is currently seeking motivated individuals to join our team in various entry-level positions. Whether you're starting your career in healthcare or seeking new opportunities to make a difference, we have roles available across our primary and specialty clinics, urgent care centers, and upcoming standalone Emergency Department. With over 7,000 employees, Lakeland Regional Health offers a supportive work environment where you can thrive and grow professionally.

Position Summary

The Clinical Documentation Integrity Liaison reports to the Manager of Clinical Documentation Integrity. This hybrid position develops and maintains physician and medical staff relationships and healthcare team members while acting as a liaison between CDI Specialists, HIM, and the hospitals’ medical staff to facilitate accurate, comprehensive, and complete documentation that supports the clinical treatment, decisions and diagnoses for the patient for coding and abstracting of clinical data; appropriate capture of severity of illness, acuity and expected risk of mortality; risk adjustment; and complexity of care of the patient. The liaison will provide education and assistance to members of the patient care team regarding documentation guidelines, including physicians, advanced practitioners, residents, allied health practitioners, nursing, and Care Management regarding documentation compliance questions, CDI physician queries, and clinical preciseness that truly reflects the patient’s care and treatment course. Responsible for reviewing patient medical records to facilitate modifications to clinical documentation through concurrent (pre-bill) interaction with providers and other members of the healthcare team to promote accurate capture of clinical treatment and to support the level of service rendered to relevant patient populations. Tracking and trending patterns for areas of opportunity CDI education. Exhibits expert knowledge of clinical documentation requirements, MS-DRG Assignment, case mix index (CMI) analysis, clinical disease classifications, major and non-major complications and comorbidities (MCCs or CCs), and quality-driven patient outcome indicators. Concurrently reviews patient records to improve documentation to reflect accurate severity of illness and intensity of service and communicates with physicians. Works collaboratively with HIM leadership, HIM Coders, and Physician Advisors to ensure accurate coding, improve the quality of DRG-related documentation, improve risk of mortality, severity of illness and case mix index. Performs other duties as assigned.

Position Responsibilities

Standard Work: Clinical Documentation Integrity Liaison

Actively participates in team development, achieving dashboards, and in accomplishing department goals and objectives.

Educates and assists members of the patient care team regarding documentation regulations and guidelines, including physicians, residents, advanced practitioners, allied health practitioners, nursing and Care Management regarding documentation compliance questions, CDI physician queries, and clinical preciseness that truly reflects the patient’s care and treatment course. Works collaboratively with the healthcare team to facilitate accurate, comprehensive, and complete documentation that supports the clinical treatment, decisions and diagnoses for the patient for coding and abstracting of clinical data, appropriate capture of severity of illness, acuity and expected risk of mortality, risk adjustment, and complexity of care of the patient.

Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation. Attends service line meetings as designated. Communicates with HIM staff and collaborates with them to resolve discrepancies with DRG assignments and other coding issues.

Identifies patterns, trends, variances and opportunities to improve documentation review processes. Tracks and trends metrics to provide education and feedback to providers on areas of concurrent documentation improvement. Gathers and analyzes information pertinent to documentation findings and outcomes and uses this information to develop action plans for process improvement.

Conducts initial and extended-stay concurrent reviews on all selected admissions for opportunities to clarify documentation in the medical record for accurate reflection of severity of illness, and documents findings. Ensures the proper reflection of each patient’s severity of illness, intensity of service, and risk of mortality. Identifies need to clarify documentation in records.

Spends a minimum of 50% of the work weeks on-site at the hospital as a resource, developing relationships and educating. Works with providers on CAPD technology and the importance of answering the recommended nudges.

Aids in identification and proper classification of complication codes and present on admission (POA) determination (patient safety indicators/hospital-acquired conditions) by acting as an intermediary between CDI, coding staff and medical staff.

Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes including Present On Admission (POA), Patient Safety Indicators (PSI), and Hospital-Acquired Conditions (HAC). Educates internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.

Formulates clinically, compliant and credible physician queries regarding missing, unclear or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary. Conducts follow-up on unanswered queries during the patient stay, as needed, to obtain a response to open queries.

Collaborates with the Physician Advisors, CDI, Coding and Quality departments and providers to identify and resolve documentation patterns and discrepancies. Collaborates with HIM/coding professionals to review and resolve DRG mismatches for individual problematic cases and ensure accuracy of final coded data in conjunction with CDI managers, coding managers, and/or Physician Advisors.

Competencies & Skills

Essential:

• Advanced clinical expertise and extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting. Strong understanding of coding application, rules, and guidelines. Ability to formulate clinically, compliant and credible physician queries.
• Working knowledge of federal, state, and private payer regulations as well as applicable organizational policies and procedures. Working knowledge of quality improvement theory and practice, core measures, safety, and other required reporting programs.
• In-depth knowledge of MS-DRG payer issues, documentation opportunities, coding guidelines and changes to include Coding Clinic, and clinical documentation requirements.
• Excellent verbal and written communication skills, analytical thinking, and problem solving with strong attention to detail. Proficiency in organizational skills and planning, with an ability to multitask in a fast-paced environment.
• Proficiency in computer use, including database and spreadsheet analysis, presentation programs, word processing, and internet research. Computer experience, especially with computerized encoder products and computer-assisted coding applications.

Qualifications & Experience

Essential:

• Bachelor Degree

Essential:

• Nursing degree (BS or BSN) or Bachelors in HIM or other healthcare related field

Experience Essential:

- 5+ years CDI auditing or education experience; coding experience; or previous CDI experience in an academic institution; or 3+ years CDI auditing or education experience; coding experience; or previous CDI experience in an academic institution with 2+ years of leadership experience.

- Experience with ICD-10-CM, ICD-10- PCS, POA, HAC, and PSI coding and documentation review and DRG analysis; OR experience with clinical documentation reviews of clinical indicators and knowledge of specificity requirements.

- Experience interacting with and educating medical staff and clinical support staff.

- Prior advanced clinical expertise and extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting.

- Experience in MS-DRG and APR-DRGs, risk adjustment, HACs and PSIs, O/E mortality, and LOS.

Experience Preferred:

- Prior experience with 3M 360 Encompass clinical application and Cerner PowerChart.

- Prior experience with 3M 360 Encompass worklist prioritization and Engage One

Certifications Essential:

- CDIP or CCDS

- If no nursing degree, must have CCS with RHIA

Licenses Essential:

- BSN if not a CCS with RHIT or RHIA

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