Clinical Quality and Care Management Coordina

POSITION SUMMARY:

The Clinical Documentation Integrity & Case Management Specialist supports accurate, complete clinical documentation while coordinating patient care needs, utilization management, and discharge planning. This role ensures that the medical record reflects patient acuity, supports quality and reimbursement, and promotes safe, efficient transitions of care. The specialist collaborates with providers, coding, case management, social work, and quality teams to optimize patient outcomes and organizational performance.

KEY RESPONSIBILITIES:

Clinical Documentation Integrity

• Review inpatient and/or outpatient medical records concurrently or retrospectively to ensure documentation accurately reflects diagnoses, procedures, severity of illness (SOI), and risk of mortality (ROM)
• Identify documentation gaps, inconsistencies, or ambiguities impacting coding, quality measures, and reimbursement
• Initiate and track compliant provider queries in accordance with AHIMA/ACDIS guidelines
• Educate providers on documentation best practices and regulatory requirements

Case Management & Utilization Review

• Perform utilization review to ensure appropriate level of care, medical necessity, and length of stay
• Collaborate with physicians and interdisciplinary teams to support efficient care progression
• Identify barriers to care and escalate concerns related to delays, resource utilization, or patient needs
• Support denial prevention and appeals through accurate documentation and clinical justification

Discharge Planning & Care Coordination

• Assess patient discharge needs, including post-acute services, equipment, medications, and follow-up care
• Collaborate with nursing and providers to develop and execute safe discharge plans
• Ensure documentation clearly supports discharge status, disposition, and continuity of care
• Promote timely discharges while maintaining patient safety and regulatory compliance
• Support transitions of care and reduce readmissions through accurate documentation and coordination

Quality, Compliance & Outcomes

• Support accurate reporting for quality metrics, patient safety indicators (PSIs), hospital-acquired conditions (HACs), readmissions, and mortality measures
• Ensure compliance with CMS Conditions of Participation, payer guidelines, and organizational policies
• Participate in audits, performance improvement initiatives, and regulatory reviews

Data Analysis & Reporting

• Monitor CDI and case management performance indicators (e.g., CMI, LOS, SOI/ROM, readmission risk, query response rates)
• Track and analyze trends related to documentation, utilization, and discharge outcomes
• Recommend process improvements to enhance efficiency, quality, and financial performance

Collaboration & Education

• Serve as a liaison among providers, coding, case management, social work, quality, and revenue cycle teams
• Participate in interdisciplinary rounds and care coordination meetings
• Assist with staff education, onboarding, and mentoring as needed

JOB QUALIFICATIONS:

• Active LPN license
• Strong clinical knowledge and understanding of care coordination and discharge planning
• Knowledge of ICD-10-CM/PCS coding, DRG methodologies, and utilization management principles
• Experience with EHR systems and CDI or case management software
• Excellent communication and organizational skills

Preferred Qualifications

• CDI certification (CCDS, CCDS-O, CDIP) and/or Case Management certification (CCM, ACM)
• 2+ years of experience in CDI, case management, utilization review, or clinical care coordination
• Experience with value-based care, risk adjustment, or population health
• Familiarity with CMS, payer, and regulatory requirements impacting documentation and discharge planning
• 5+ years Medical/Surgical or ICU experience

Key Competencies

• Clinical judgment and critical thinking
• Care coordination and discharge planning expertise
• Documentation accuracy and attention to detail
• Provider communication and education
• Analytical and problem-solving skills