Clinical Documentation Integrity Specialist-Full-Time

CLINICAL DOCUMENTATION INTEGRITY SPECIALIST

Qualifications

• Active RN License

JOB REQUIREMENTS

• The (Hospital) Clinical Documentation Integrity (CDI) Specialist will perform concurrent and retrospective reviews of inpatient records for documentation compliance. Communicate effectively with Providers regarding missing, unclear, or conflicting health record documentation and identify opportunities to clarify Principal Diagnoses, Secondary Diagnoses, Procedures and Quality Indicators. Promote accurate capture of clinical severity to support level of service rendered to patients.
• Demonstrate an understanding of complications, comorbidities, severity of illness (SOI), risk of mortality (ROM) case mix, and the impact of procedures on the billed record, as well as the ability to impart this knowledge to providers and other members of the healthcare team.

DUTIES AND RESPONSIBILITIES

• Performs concurrent and retrospective review of inpatient records and identifies opportunities to improve quality of documentation.
• Communicate with providers to promote accurate and complete documentation of diagnoses and/or procedures in the health record.
• Generates compliant, clinical queries for clarifying Principal Diagnoses, Secondary Diagnoses, Procedures, Severity of Illness (SOI), Risk of Mortality (ROM) and Quality Indicators
• Provides clinical support for Coding Team and performs clinical validation
• Collaborate with Providers, Case Managers, Coding Team and Health Information Management Professionals to ensure coding accuracy, and address DRG discrepancies
• Reports to Hospital Leadership and designated Facility Director
• Provides CDI education to Hospital Leadership, Physicians, Clinicians, Coders and Health Information Management Professionals to improve documentation quality and to optimize quality of patient care
• Creates reports summarizing identified trends, variances, analyses, and CDI impact
• Participates in meetings with Hospital Leadership, Department Chairs, Division Chiefs, Physicians, Clinical Teams, Coding Teams and Health Information Management Professionals to provide feedback and suggestions for improvement of documentation quality

MINIMUM REQUIREMENTS

• CDIP, CCDS or CCS credential preferred
• 3+ years working experience as CDI Specialist for Inpatient Facility
• 3+ years working experience with ICD-10-CM/PCS code sets and MS-DRG and APR-DRG payment models
• Expertise in CDI workflow and adherence to AHIMA Query Guidelines
• Adherence to ICD-10-CM/PCS Official Guidelines for Coding and Reporting, AHA Coding Clinic, ACDIS ethical guidelines, AHIMA Standards of Ethical Coding, CMS and other regulatory guidelines
• Proficiency in Microsoft Word, Excel and PowerPoint
• Excellent critical thinking skills
• Knowledge of Utilization Review preferred
• Excellent oral and written communication skills
• Ability to complete projects and meet deadlines with time constraints
• Assists with Utilization Review and Discharge Planning