Under minimal direction, the Clinical Documentation Improvement (CDI) Specialist will provide active concurrent/retrospective review of inpatient medical records, provide feedback and educate clinical care providers to improve the documentation of all conditions, treatments and care plans within the health record to accurately reflect the condition of the patient and promote patient care. In addition, documentation should reflect documentation associated with MS-DRG assignment, case mix index, severity of illness, risk of mortality, physician profiling, and hospital profiling and reimbursement rules.
In this role, you will facilitate improvement in medical record documentation by interacting with and educating physicians, nurses and coding staff to ensure medical records accurately reflect patient acuity for quality reporting and reimbursement. The ideal candidate will thrive in a fast-paced environment, with high physician and coding staff interaction.
CCS AHIMA certification required
ACDIS CDI certification or AHIMA CDIP certification required
At least 2 years experience as CDI-S in acute clinical environment (not remote) required.
Strong clinical knowledge and demonstrated commitment to maintaining relevancy in clinical field
Familiarity with ICD-10-CM Official Coding Guidelines
Excellent written and verbal communication skills, critical thinking skills, listening skills and interpersonal skills to build effective partnering relationships with physicians, care management team, nursing staff, coding staff and other hospital staff
Ability to work independently in a time oriented environment
Ability to analyze problems and issues from a variety of perspectives and understand the legal, reimbursement and impact