Clinical Documentation Improvement Specialist

The Clinical Documentation Integrity (CDI) Specialist will collaborate with physicians, nursing staff, other patient caregivers, and medical records coding staff to improve the quality, specificity, accuracy, and completeness of documentation of care provided and coded. They will review medical records for opportunities for diagnosis clarification and validity as it pertains to DRG assignment, severity of illness, risk of mortality, and case mix data, as well as clinical indicators (HACs, PSI, mortality, etc.). This role will adhere to all coding and clinical documentation improvement guidelines endorsed by ACDIS and AHIMA, while following AHIMA guidelines and Health Information Associates policies and procedures. 

Required Skills and Experience

• Recognized CDI credential from ACDIS (CCDS)

• Current RN license

• Current AHIMA or AAPC coding credential preferred

• Three or more years of experience working as a clinical documentation specialist

• Three years or more of clinical experience in an acute care setting

 

• Adhere to all coding and clinical documentation improvement guidelines endorsed by ACDIS and AHIMA

 • Analyze records for potential query opportunities, appropriate DRG assignment, severity of illness, risk of mortality, and case mix data, as well as clinical indicators (HACs, PSI, mortality, etc.)

• Research, analyze, and respond to inquiries regarding queries issued and their compliance, potential coding errors, diagnoses at risk for denials, and reconciliation of CDI reviewed charts.

• Conduct clinical documentation reviews and audits as assigned meeting productivity standards set by record type for each project or client.

• Communicate with coworkers and clients professionally and respectfully to promote teamwork and knowledge sharing.

• Provide a schedule of planned work activities, events, and sites to management and appropriate staff.

• Maintain professional credentials and knowledge of CDI, coding, reimbursement, and compliance issues through continuing education.

• Periodic travel may be required.

• Strong analytical skills and ability to work with numbers.

• Ability to work well with multiple and diverse clients and projects.

• Ability to work with minimal supervision while maintaining high levels of accuracy and attention to detail.

 

• Maintains strict confidentiality and adheres to HIPAA guidelines

• Exhibits professional demeanor at all times

• Maintains communication by responding promptly to corporate office staff

• Demonstrates flexibility, open mindedness, and versatility in adjusting to changing environments

• Handles constructive feedback with a positive attitude

• Receptive to suggestions for changing or improving the way work is accomplished.

• Commits to continually improving his/her job skills