Hospital - CDI Specialist, Associate

• Responsible for the day-to-day evaluation of documentation by medical staff and patient caregivers.
• Ensure the accuracy and completeness of clinical information used for reporting severity of illness, risk of mortality, DRG and hospital outcomes.
• Using expert clinical knowledge, initiate compliant and effective verbal and written queries for points of clarification of the documentation in the medical record.
• Conducts follow-up reviews of clinical documentation to ensure the completeness and consistency of the level of care provided to the patient.
• Tracks and escalates HAC and HARM quality measures.
• Assists with clinical validation reviews related to the denials and appeals process.
• Assists CDI supervisor with developing provider education strategies to promote complete, accurate, and comprehensive medical record documentation.
• Assists with mentoring or training new Clinical Documentation Integrity Specialists.
• Analyzes data and reports quality issues to CDI Supervisor.
• Supports meeting organizational unbilled goals for Accounts Receivable with uncoded accounts.
• Performs all aspects of daily work in a manner that contributes to and ensures an environment of strict confidentiality.
• Performs all other duties as assigned.

• Knowledge of Official Guidelines for coding and reporting.
• Knowledge of medical terminology, human anatomy, physiology and pharmacology.
• Knowledge of disease pathology.
• Knowledge of ICD-10-CM/PCS.
• Knowledge of DRG payor regulations, documentation opportunities, and clinical documentation requirements.
• Ability to interpret data in order to improve documentation practices.
• Knowledge of operating ordinary business equipment in a remote and office environment, such as computers, keyboards, and telephones.
• Ability to work effectively in and navigate between common office software, coding software, billing software, and abstracting systems. Knowledge of coding resources and demonstrated proficiency in using resources.
• Ability to troubleshoot basic technical issues in the remote and office environment.
• Ability to communicate effectively with providers and patient care givers.
• REQUIRED QUALIFICATIONS:  RN, RHIT, RHIA, CDIP, or CCDS.

EDUCATION:

HS Diploma or GED

Must have Clinical Experience