Clinical Dcmntn Spec Ex
The Clinical Documentation Improvement Specialists (CDI) reports to the Director of HIM. They will provide concurrent review of clinical documentation in the medical record by a thorough chart review to identify severity, comorbidities, complications, working DRG’s and procedures. They will work collaboratively with the medical staff, providers and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality. Collaborate with physicians, physician extenders, nurses, case managers and Medical Record coders to identify principal diagnosis options, secondary diagnoses, procedures, assign working DRGs and identify educational opportunities. CDI is able to identify and communicate areas of focus through report analysis.
- Conduct audits and reviews to ensure all documentation is accurate and precise
- Contact physicians and other health care professionals with questions about treatments or diagnostic tests given to patients with regard to coding procedures
- Provides concurrent review of clinical documentation in the medical record.
- Performs a thorough chart review and assignment of codes to identify severity, working DRGs, secondary diagnoses, procedures and complications.
- Collaborates with and queries the medical staff, providers and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality.
- Documents all queries and their resolution.
- Identifies educational opportunities and collaboratively shares information for resolution. Including but not limited to training materials, presentations and leading group classes.
- Able to identify areas of focus through report analysis.
- Other Duties as assigned.
Experience and Qualifications:
- REQUIRED: RN or CDIP or CCDS
- At least two - five years’ experience in an inpatient setting and working with CMS regulatory requirements’.
- Experience with ICD-10 CM, MS-DRGs and documentation guidelines.
- Excellent problem solving skills, the ability to work independently, and to perform under pressure in a positive, teamwork manner with diplomacy and tact.
- Interpersonal verbal and written communication skills to accurately relay information to staff and to internal and external customers.
- Proficient computer skills and Microsoft Office
- Licensure/Registration and/or Certification:
- Required RN, or CCDS or CDIP