Clinical Documentation Improvement Specialist (FT- 1.0 FTE, Day Shift, Remote Possible)

Position Summary

The Clinical Documentation Improvement Specialist (CDIS) conducts concurrent reviews of inpatient medical records to enhance the quality, accuracy, and completeness of documentation. Utilizing clinical expertise and current coding systems (ICD-10-CM & PCS), the CDIS ensures proper code assignment and alignment with the patient’s clinical condition and care provided. The role involves collaborating with providers through education and the physician query process to support severity of illness, quality metrics, and regulatory compliance. Additionally, the CDIS maintains expertise in coding principles, government regulations, and third-party requirements while serving as a resource for clinicians, coders, and Revenue Cycle teams.

Minimum Qualifications

• Required Bachelor's degree in Nursing (RN) with current Registered Nurse (RN) licensure; OR Graduate of an accredited or equivalent international medical program or advanced medical program (MD, DO, NP, MBBS or equivalent); OR Ten (10) years of experience in Clinical Documentation Improvement (CDI) in an acute care setting
• At least one of the following CDI or coding credentials/certifications:
  • Certified Coding Specialist (CCS)
  • Certified Clinical Documentation Specialist (CCDS)
  • Certified Documentation Improvement Practitioner (CDIP)
  • Registered Health Information Administrator (RHIA)
  • Registered Health Information Technician (RHIT)
• Preferred Three (3) years of experience in one of the following areas:
  • Medical/Surgical or Critical Care nursing
  • Clinical Documentation Improvement (CDI) or Inpatient Coding in an acute care setting
  • Experience with Epic and 3M 360 Encoder systems

Essential Job Functions

• Ensure ethical, accurate, and complete coding by adhering to current coding practices, guidelines, and conventions when assigning DRGs, diagnoses, and procedures.
• Conduct concurrent medical record reviews for inpatient admissions, assigning a working principal diagnosis, secondary diagnoses, procedures, and DRG.
• Follow CDI processes for querying providers, reconciling DRG or diagnosis assignments with facility coders, and resolving physician queries before patient discharge.
• Collaborate with healthcare professionals, including physicians, advanced practice providers, case managers, and coders, to ensure documentation accurately reflects severity of illness, risk of mortality, and level of services provided.
• Utilize designated clinical documentation systems (e.g., 3M 360, Epic) to identify documentation improvement opportunities and enhance hospital outcomes.
• Maintain compliance with HIPAA regulations to ensure data security and patient confidentiality.
• Participate in team, clinician, and interdepartmental meetings, as well as training, shadowing, and education initiatives for staff related to compliance, coding, and CDI best practices.
• Provide education and act as a consultant to coders and clinical staff when additional documentation or clarification is needed for accurate DRG assignment and coding compliance.
• Identify and recommend process improvements and efficiencies within CDI and coding workflows while monitoring and reporting patterns, trends, and variances in documentation.
• Generate scheduled reports and other reports as requested to track CDI effectiveness and documentation trends.
• Stay up to date with CMS regulations and industry best practices, researching literature and incorporating changes into daily CDI practice.
• Meet productivity and quality standards as designated by the System Manager of CDI and complete special projects as assigned.

Knowledge, Skills And Abilities

• Exercises tact, discretion, sensitivity, and maintains confidentiality
• Learns current and new computer applications and office equipment utilized at Bozeman Health
• Strong interpersonal, verbal, and written communication skills
• Analyzes, organizes, and prioritizes work while meeting multiple deadlines

Physical Requirements

• Lifting (Rarely – 30 pounds)
• Sit (Continuously)
• Stand (Occasionally)
• Walk (Occasionally)
• Climb (Rarely)
• Twist/Bend/Stoop/Kneel (Occasionally)
• Reach Above Shoulder Level (Occasionally)
• Push/Pull (Occasionally)
• Fine-Finger Movements (Continuously)
• Vision (Continuously)
• Cognitive Skills (Continuously)

Job Tasks

• Learn new tasks, remember processes, maintain focus, complete tasks independently, and make timely decisions in the context of a workflow
• Exposures (Rarely): Bloodborne pathogens, radiation, various chemicals and medications, cleaning products, disinfectants, infectious diseases