Clinical Documentation Improvement Officer

Sheikh Shakhbout Medical City

The Clinical Documentation Improvement Officer collaborates extensively with the physicians, nursing staff, other patient caregivers and coding staff, quality department, and HIM staff to improve the quality and completeness of documentation of care provided and coded for coordination, abstraction, and submission of accurate data required by Department of Health (DOH) and all payers.

Facilitates concurrent modifications to clinical documentation to secure the appropriate reimbursement of clinical severity and services rendered to patients with a Diagnosis Related Group, official coding guidelines as well as other methodologies published by DOH. Supports timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. Communicates with and educates all hospital staff including but not limited to all the physicians, nursing, care management, allied health practitioners, coders, and other patient financial-service staff. Supports denial management team in providing the references to provide justifications related to clinical documentation.

Clinical Documentation Improvement Specialist

• Review concurrent medical records for compliance including completeness and accuracy for the severity of illness (SOI), risk of mortality (ROM), patient safety indicators (PSI), hospital-acquired conditions (HACs), and quality of the documentation.
• Complete accurate and timely record reviews to ensure the integrity of documentation compliance.
• 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.
• Identifying the documentation gaps and getting the documentation updated by the care provider by developing the queries in compliance with ethical documentation standards with the clinical validation and references from the documentation.
• Work closely with the physician champions, clinical coders, case managers, nursing staff, and quality departments in resolving queries and updating the documentation.
• Concurrently update the CDI tool with the findings and remarks based on the documentation review to validate and monitor the CDI metrics.
• Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including attending physicians, allied health practitioners, nursing, and care management.
• 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 resolve discrepancies with DRG assignments and other coding issues.
• Complete well-timed follow-up case reviews on all concurrent cases with priority given to resolution of those with clinical documentation clarifications
• Participate in meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified.
• Use the available systems and applications to generate the reports and provide the statistics to the stakeholders in a periodic manner.