Clinical Documentation Improvement Specialist

The Clinical Documentation Specialist is responsible to ensure that the quality of clinical documentation meets and exceeds all Federal, State, and Payor requirements within a variety of levels of care. The CDI Specialist is responsible for delivering qualitative analytics of care that is provided and reflected in the medical records to the Operations team. Analytics will be utilized to target both site and/or practitioner specific interventions thus driving positive patient outcomes.

Responsibilities

• Performs retrospective and concurrent reviews of patient accounts to identify potential diagnosis opportunities to support accurate, complete and compliant coding, documentation and educational opportunities

• Develop qualitative analytic reports on key metrics

• Monitoring of patient charts to ensure operational initiatives are adopted

• Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to support the level of service rendered to all patients as assigned

• Provides clarity of clinical information used for measuring and reporting physician and medical center outcomes which incorporates current DRG methodologies (e.g., MS-DRG, LTAC) by CMS and/or other regulating/quality reporting bodies (e.g., APR-DRG)

• Assist in the development of internal coding and documentation guidelines in accordance with official coding guidelines

• Provides education to the providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record

• Assists in development and training of CDI principles

Qualifications

Strong working knowledge of clinical documentation expectations to include:

• Current knowledge and understanding of ICD-10-CM and risk adjustment coding through participation in education and training including comprehension of ICD-10-CM Official Guidelines for Coding and Reporting, Coding Clinic, and other regulatory education programs and updates

• Proficient knowledge of the Coding and Documentation Guidelines and standards of risk adjustment

Required Minimum Education

• Bachelor or Associate degree in Health Information Management, Business, or other health care related field preferred or 5 years of relevant work experience in lieu of degree.

Required Minimum Certification

At least one of the following:

• Licensure/certification: The candidate should be currently licensed as an RN, LPN or possess active RHIA/ RHIT.
• Certified coding specialist (CCS)
• Certified Documentation Improvement Practitioner (CDIP)
•  Clinical Documentation Expert Outpatient (CDEO)
•  Certified Clinical Documentation Specialist CCDS

Required Minimum Experience

• Five years of acute care experience, or as a registered health information administrator or technician (RHIA/RHIT) with at least five years inpatient coding experience.
• Candidate should also have advanced clinical expertise and extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting.