Clinical Documentation Improvement; CDI) Specialist

Your job is more than a job

The Clinical Documentation Improvement (CDI) Specialist facilitates complete and accurate documentation of medical records on an ongoing basis, at the point of service. To communicate and educate the medical staff members, coders, clinicians, and other facility employees regarding updates, guideline changes. Must communicate with physicians, case managers, coders, and other health team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients and outpatients.

Conducts reviews and analyses of health records for inpatient/outpatient and clinical encounters to identify relevant diagnoses. Provides direction for concurrent modification to clinical documentation to ensure appropriate coding for reimbursement for clinical severity and services provided to the patients. Maintains accurate and complete documentation of clinical information used to measure and report physician and facility outcomes.

Collaborates extensively with physicians/providers, nurses, or other healthcare providers and coding staff to improve quality and completeness of documentation of care provided and coded. Queries physician/providers to clarify ambiguous, conflicting, or incomplete documentation. Collaborates with interdisciplinary teams including, but not limited to Physician Advisors (PAD), physicians, nurse practitioners, PA’s, mid-level practitioners, and the department managers for Revenue Integrity, Coding, Data Quality, Case Management and Health Information Management.

Provides ongoing education to all members of the patient care team. Facilitates modification to clinical documentation to ensure that the medical record presents an accurate patient clinical picture and intent of the provider.

Conducts concurrent and retrospective review of the medical records to increase the accuracy, clarity, and specificity of provider documentation.

Accountable for attainment of goals and revenue cycle key performance indicators (KPI’s) as defined by the department. Maintains communication with management on backlogs and keeps abreast of necessary situations as it relates to patients, physicians, and any other healthcare providers.

• Bachelor’s Degree in Nursing or HIM
• 2 years of experience in Clinical / Nursing & Case Management or Coding with an Associate’s Degree
• Must have one of the following certifications/licensures:
  Licensed Registered Nurse/BSN, LPN (must be licensed in the state of Louisiana), Certified Clinical Documentation Specialist, RHIA, RHIT or Coding Certified from AHIMA/AAPC.

• Knowledge as it relates to, but not limited to, electronic health record, health information systems and healthcare applications and their effects on Coding practices today and in the future.
• High ethical standards.
• Knowledge of ICD-10-CM, ICD-10-PCS, CPT/HCPS, MS-DRG, APR-DRG and APC coding guidelines.
• Extensive knowledge of hospital and professional coding including provider based billing.
• Experience with concurrent reviews.
• Knowledge of medical terminology, classifications systems and vocabularies.
• Knowledge of privacy and security regulations, confidentiality, laws, access and release of information practices.
• Experience in assisting and identifying learning needs as well as providing education and training designed to support a learning organization.

• Excellent oral, written and interpersonal communication skills.
• Ability to organize and set priorities to ensure objectives are met in a timely manner.
• Ability to adapt to change and handle challenges…