CDI Specialist I Inpatient

About the role

The role involves facilitating improvement in clinical documentation to ensure accurate coding, severity of illness, and risk of mortality. This includes extensive interaction with and education of providers and multidisciplinary team members.

Responsibilities

• Identifies and records principal diagnoses, secondary diagnoses, procedures, and assigns DRGs.
• Conducts initial concurrent review and ongoing re-reviews for all selected admissions.
• Identifies need to clarify documentation through quality audits and communicates with providers using appropriate query tools.
• Provides information and ongoing education on documentation issues, guidelines, and unanswered queries.
• Promotes compliance with CMS, Medicare documentation, and coding and billing regulations.
• Participates in assessing and improving services and compliance with regulatory requirements.
• Reports results of assessment and improvement processes to appropriate administrative levels.
• Collaborates with the Quality Department to ensure documentation meets quality initiative standards.
• Collects, analyzes, and submits reports of clinical documentation information for measuring and reporting hospital and provider outcomes.
• Facilitates education and training of new associates concerning clinical documentation improvement guidelines and processes.
• Works with Coding Specialists to resolve issues related to documentation, providers, and queries.

Requirements

Three (3) years inpatient acute care coding or CDI experience, or three (3) years clinical experience as Registered Nurse or Licensed Practical Nurse in an inpatient acute care setting. Preferred qualifications include two (2) years of CDI experience.

Qualifications

High School Diploma or Equivalent. Experience in Risk Adjusted Coding or Evaluation and Management is preferred. Must possess excellent written and verbal communication skills, as well as interpersonal skills necessary to communicate effectively. Knowledge of related provider healthcare compliance, revenue cycle operations, and auditing techniques is required. Must possess the ability to accept mentoring, education, and training from others. Must meet quality and productivity standards. Must be able to concentrate and maintain accuracy during constant interruptions. Must possess organizational and time management skills. Must possess the knowledge of anatomy, physiology, and medical terminology. Must possess analytical and problem-solving skills. Must be proficient in office software programs. Must be able to work independently with minimal supervision.

Skills and Abilities

• Excellent written and verbal communication skills.
• Interpersonal skills necessary to communicate effectively.
• Knowledge of related provider healthcare compliance, revenue cycle operations, and auditing techniques.
• Ability to accept mentoring, education, and training from others.
• Meets quality and productivity standards.
• Accepts changes in the workplace and work assignments.
• Organizational and time management skills.
• Knowledge of anatomy, physiology, and medical terminology.
• Analytical and problem-solving skills.
• Proficient in office software programs.
• Able to work independently with minimal supervision.

Benefits

N/A

Pay

N/A

Schedule

N/A