Description

Job Summary

The CDI Risk Adjustment Specialist reports to the Senior Manager, CDI Risk Adjustment and conducts advanced second level clinical documentation reviews for inpatient encounters focusing specifically on documentation opportunities supporting risk-adjusted methodologies to accurately reflect the quality of care being delivered across MGB. This role focuses on improving quality outcomes through improvement of risk-adjusted reporting impacting the O/E for multiple MGB enterprise quality initiatives while adhering to CDI established policies, procedures, and professional guidelines.

Principle Duties and Responsibilities

Perform Risk Adjustment CDI reviews to identify discrepancies or missed opportunities in clinical documentation that impact quality outcomes through risk-adjusted measures, specifically Vizient and Elixhauser variables.

Accurately interpret clinical information in the health record and evaluate clinical indicators to identify potential diagnoses and query opportunities impacting quality outcomes.

Issue clinically credible and compliant queries to providers as appropriate with focus on addressing organizational quality initiatives.

Escalate complex cases to the CDI leadership team or physician advisors, as needed.

Track and report clinical documentation or CDI issues affecting quality measures.

Maintain up-to-date knowledge of CDI practices, inpatient coding guidelines, CMS/OIG regulatory changes, and AHA Coding Clinic.

Work collaboratively with vendor-supported primary CDI Specialist workforce to ensure accurate clinical documentation and appropriate principal diagnosis assignment for all reviewed encounters.

Meet or exceed MGB CDI Risk Adjustment Specialist key performance indicators.

Use the Mass General Brigham values to govern decisions, actions and behaviors. These values guide how we get our work done: Patients, Affordability, Accountability & Service Commitment, Decisiveness, Innovation & Thoughtful Risk; and how we treat each other: Diversity & Inclusion, Integrity & Respect, Learning, Continuous Improvement & Personal Growth, Teamwork & Collaboration.

Other duties as assigned

Requirements

Qualifications
Registered Nurse (RN), Advanced Practice Clinician (NP/PA), or other clinically licensed professional
5 years of acute medical/surgical care experience required
3-5 years of advanced clinical documentation improvement experience required
Certification in Clinical Documentation preferred
 

Skills Abilities, and Competencies

In-depth knowledge of clinical disease processes and inpatient care delivery
Demonstrated proficiency in risk-adjustment CDI knowledge, specifically Vizient and Elixhauser methodologies
Advanced understanding of risk adjustment methodologies impacted by clinical documentation.
Can explain observed-to-expected ratios and their calculation
Advanced understanding of MS-DRG/APR-DRG logic, SOI/ROM methodology, and CC/MCC assignment
Strong analytical, critical thinking, and clinical reasoning skills
High attention to detail and commitment to accuracy and compliance
Excellent written and verbal communication skills
Proficiency in CDI software systems to document, track, report outcomes and interact with coding professionals
Knowledgeable about current CDI industry trends
Proactive in researching and resolving clinical and CDI questions
Self-driven, able to prioritize tasks, and adapt quickly to change
Dedicated to continuous learning and professional growth
Team-oriented with strong collaboration skills