CDI Specialist

Primary Function

Under the direction of CDI Manager, the Clinical Documentation Specialist reviews medical records to facilitate accurate and complete medical record documentation to reflect clinical treatment, decisions, and diagnoses used for measuring and reporting hospital and physician outcomes. Accurately identifies additional documentation opportunities and places appropriate queries and/or communicates with physicians, coders, and other health team members (i.e. PI, Case managers, Nurse navigators, etc.) for documentation improvement.

Essential Functions

• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.
• Accurately reviews medical records concurrently for completeness in documentation of diagnostic and procedural information for compliance to CMS, DOH regulatory, and financial requirements.
• Safeguards documentation of diagnoses, procedures, co-morbid, and complication conditions are reflected on the medical record to support proper severity of illness, intensity of service, and risk of mortality classifications and designated quality reviews (i.e. Patient Safety Indicator reviews).
• Prepares well written and compliant queries to communicate with physicians and other providers regarding missing, incomplete or clarifying information needed in the medical record.
• Works closely with coding staff to assure that documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care.
• Interacts and continuously educates physicians (attending’s, residents and interns), nurse practitioners and physician assistants. Provides real-time intervention/education when needed to promote correct coding, regulatory compliance, and correction of documentation deficiencies.
• Comprehensive working knowledge of HIPPA PHI and all laws relative to access PHI (protected Health Information).
• Maintains productivity expectations. Accurately records activity in CDI software tracking tool.
• Expert working knowledge of computer applications, ie; Epic EHR, 3M DRG, MS Office.
• Maintains appropriate registration/certification.
• Tracks and trends issues identified during concurrent reviews.
• Attends department meetings. Actively contributes to the continued improvement and success of the department and the hospital.
• Attends continuing education meetings, in-services, and training sessions and audioconferences related to coding and CDI to maintain skills and stay abreast of coding guideline changes and best practice CDI processes.
• Demonstrates initiative, judgement and creative ability in performance of job duties.
• Identifies problems with process and suggests possible solutions.

Education/Training Requirements

• Bachelor of Science in Nursing
• Bachelor of Science in Health Information Management or related field.
• Certification, Associate or Bachelor in other healthcare related field with experience noted below.
• CCDS, CDIP certification preferred
• RN/BSN preferred
• RHIA, or RHIT with CCS, MD or DO will be considered
• CCDS within 6 months of hire for eligible candidates
• Maintenance of appropriate registration/certification.

Experience Requirements

• Working knowledge of Medicare reimbursement system and coding structures preferred.
• 5 years of Critical Care/Emergency medicine or 5 years of Medical Surgical Experience preferred.
• 2-3 years Clinical Documentation Improvement experience or 5 years of Coding experience preferred.
• MD/DO with two years of experience as a concurrent or retrospective coder or documentation specialist in an inpatient acute care facility using the United States IPPS system will be considered.

Additional Information

• Familiarity with computers and Microsoft Office applications required.
• Ability to work independently with minimal supervision.
• Motivated, organized with excellent Interpersonal skills, analytical skills.
• Strong facilitation and presentation skills preferred.
• Ability to read and communicate in the English Language.

Disclaimer

This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.