CDI Consultant (PT)

About the role

The Clinical Documentation Integrity (CDI) Consultant will provide timely reviews of patient medical records to ensure accurate and complete documentation to reflect the patient’s severity and complexity of illness. The CDI Consultant is expected to work with providers and coders to ensure that documentation on the chart reflects the complexity of the patient. The ability to educate and interact with providers is essential.

Responsibilities

• Review medical records as assigned for complete and accurate documentation of all relevant diagnoses and procedures
• Initiate and complete queries as necessary to reflect accurate data regarding the patient’s inpatient or outpatient visit
• Adhere to guidelines as set forth by ACDIS, AAPC, and AHIMA
• Maintain strict confidentiality of all patient information in accordance with HIPAA
• Demonstrate understanding of the business of healthcare: DRG payer issues, audit risks, documentation opportunities, quality metrics, hierarchical condition categories
• Work closely with the client, co-workers, and management to meet the specific needs of each assignment in alignment with core values
• Effectively utilize computer software based on the specific client requirements

Requirements

• 2+ years of clinical documentation experience
• Current RN license or graduate of medical school with 5+ years of acute care experience preferred; some clients may require RN
• Strong analytical skills to clinically evaluate the medical record
• Ability to use a PC for medical record review along with proficiency utilizing Microsoft products (Excel, Word, Outlook)
• Ability to communicate effectively with e4health management and clients

Preferred Qualifications

• CCDS or CDIP certification
• BSN, in addition to RN license, is preferred

Benefits

• Excellent salary
• Full benefits package including 401(k) with company match
• Medical, dental, vision, life, and short/long term disability insurance
• PTO policy

Physical Demands

• Sitting, talking, hearing and near vision are required over 90% of the time
• Feeling is required over 90% of the time and reaching is required about 50% of the time
• The ability to travel to field sites may be required up to 15% of the time

Working Conditions

• Over 90% of the time is spent indoors, with protection from weather conditions
• Exposure to noise levels that may be distracting or uncomfortable is present only in unusual situations