Strength Through Diversity
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The CDI Specialist is responsible for improving the overall quality and completeness of clinical documentation; facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to ensure that documentation reflects complete and accurate level of service rendered to patients.
Duties and Responsibilities
- Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through concurrent auditing and evaluation of the medical records.
- Facilitates accurate clinical documentation to ensure appropriate DRG classification is received for the level of service rendered to all patients with a Diagnosis-Related Group (DRG) payor.
- Analyzes clinical status of patient, current treatment plan and past medical history to identify potential gaps in clinical documentation.
- Ability to write queries that are concise and easily understood by the queried provider, in order to garner additional necessary documentation in the inpatient medical record
- Timely reconciliation of all cases, to include accurate recording of DRG or SOI impact based on physician query, as well as physician response to all queries
- Identify query opportunities, diagnoses not supported by clinical indicators, and function on par with other CDI team members.
- Demonstrate an understanding of complications, comorbidities, SOI, 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
- Monitors activities to ensure that all clinical documentation is in compliance with State and Federal payor regulations.
- Collaborate with HIM/coding professionals to review individual problematic cases and ensure accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisors.
- Communicate with appropriate healthcare team members to promote accurate and complete documentation of diagnoses and/or procedures in the health record that have direct bearing on SOI.
- Act as a consultant to coding professionals when additional information or documentation is needed to assign coded data and clinical validation.
- Performs other related duties.
- Certification with one of the following: CCA (Certified Coding Associate), CCS (Certified Coding Specialist), CDIP (Certified Documentation Improvement Practitioner), or CCDS (Certified Clinical Documentation Specialist
- Bachelor Degree preferred -OR- RN (5 years registered nurse experience in med-surgical, critical care or emergency care) -OR- foreign medical graduate.
- 1-2 years of CCA, CCS, CDIP or CCDS experience or equivalent
- Thorough knowledge of ICD-10, CPT, and HCPCS - preferred