Clinical Documentation Improvement – CDI – Specialist

Clinical Documentation Improvement – CDI – Specialist

Requirements

• Bachelor’s degree
• One of the following: RN, MD, or MD Equivalent (MBBS)
• 2-4 years acute care inpatient hospital coding or CDI experience
• Familiarity with encoder and DRG assignment
• Maintain current working knowledge of official coding guidelines and coding clinics

Responsibilities

• Conducts daily, concurrent review of inpatient records on assigned unit(s) to ensure complete and accurate physician and or clinician documentation is present at the time of discharge for accurate, timely, and compliant coding.
• Reviews daily admissions to assigned unit, perform initial code assignment for a working DRG and complete CDI software data entry for initial and follows up case reviews (or worksheet to include code and DRG assignment) and submit to Program Assistant.
• Updates ‘working DRG’ as documentation supports, or physician query answer supports a change in the DRG assignment.
• Communicates to the CDI Coordinator when volume of daily review assignments is too high or low so that CDI Coordinator can assist in adjusting review assignments amongst the team.
• Initiates compliant physician queries when documentation is confusing, ambiguous, or missing and follows up with MD to seek immediate response to query (utilizing the following AHIMA practice briefs as a guide: ‘Managing an Effective Query Process,’ October 2008 and ‘Guidance for Clinical Documentation Improvement Programs’, May 2010).

Preferred Qualifications

• CCDS, CDIP preferred
• Strong clinical understanding of disease process
• Demonstrate critical thinking, analytical skills, and ability to resolve problems.
• Strong knowledge of medical terminology, anatomy, physiology, microbiology, and disease processes
• Ability to converse with physicians in sometimes difficult scenarios
• Strong typing and computer skills; proficiency with EHR systems, CDI software systems and encoders