Clinical Documentation Improvement Specialist
New
Arizona, Florida, Georgia, Idaho, Iowa, South Dakota, Texas, South Carolina, Wisconsin, North Carolina, Michigan, MontanaFull-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- Ten (10) years of experience in Clinical Documentation Improvement (CDI) in an acute care setting if not holding specific degrees; Preferred: Three (3) years of experience in Medical/Surgical or Critical Care nursing or CDI/Inpatient Coding.
- Required Skills
- HIPAA
Requirements
- Bachelor's degree in Nursing (RN) with current Registered Nurse (RN) licensure
- Graduate of an accredited or equivalent international medical program (MD, DO, NP, MBBS or equivalent)
- Ten (10) years of experience in Clinical Documentation Improvement (CDI) in an acute care setting
- Certified Coding Specialist (CCS)
- Certified Clinical Documentation Specialist (CCDS)
- Certified Documentation Improvement Practitioner (CDIP)
- Registered Health Information Administrator (RHIA)
- Registered Health Information Technician (RHIT)
- Three (3) years of experience in Medical/Surgical or Critical Care nursing (preferred)
- Three (3) years of experience in CDI or Inpatient Coding in an acute care setting (preferred)
- Experience with Epic and 3M 360 Encoder systems (preferred)
Responsibilities
- Ensure ethical, accurate, and complete coding by adhering to current coding practices, guidelines, and conventions.
- 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.
- Utilize designated clinical documentation systems (e.g., 3M 360, Epic) to identify documentation improvement opportunities.
- Identify medical record data integrity issues and escalate concerns related to coding, CDI functions, or EHR systems.
- Participate in team, clinician, and interdepartmental meetings, as well as training, shadowing, and education initiatives.
- Provide education and act as a consultant to coders and clinical staff.
- Identify and recommend process improvements and efficiencies within CDI and coding workflows.
- Generate scheduled reports and other reports as requested to track CDI effectiveness and documentation trends.
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