CDI Specialist | Corp| Remote

Orlando Health • Orlando, FL

169d • Remote

About The Position

The CDI Specialist III provides concurrent review of the clinical documentation in the medical record, identifying any missing or understated diagnoses or procedures. This role involves reviewing the medical record with a clinical lens to ensure accurate reflection of patient acuity and justifying the level of care. The position is remote and offers flexibility to support work-life balance. Orlando Health is recognized as one of America's Best-In-State Employers and is committed to providing comprehensive benefits and career growth opportunities.

Requirements

• Graduate from an approved school of nursing.
• RN Licensure from FL or a Multistate Nursing Licensure.
• Must maintain current certification: CCDS, CDIP, CPC, or CCS.
• Three (3) years of clinical experience in a hospital setting.
• Two (2) years previous acute care clinical documentation improvement specialist experience required.
• Thorough knowledge of ICD-9-CM, ICD-10-CM/PCS, APR DRG, and MS DRG required.
• Excellent written and verbal communication skills.

Responsibilities

• Conducts initial and follow-up concurrent reviews on targeted admissions for opportunities to clarify documentation in the medical record.
• Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided.
• Performs thorough chart reviews to identify co-morbidities/complications and documents these appropriately.
• Determines the appropriate principal diagnosis of the patient.
• Captures all appropriate secondary diagnoses for quality rating purposes.
• Documents findings in workflow tools, noting all key information used in the tracking process.
• Develops rapport with providers to clarify information in the medical record.
• Uses appropriate querying tools to capture needed documentation.
• Queries the medical staff to obtain accurate and complete physician documentation.
• Provides education to physicians on the importance of complete documentation.
• Reviews the progress of the CDI program by interpreting performance, process, and quality ratings reports.
• Acts as a liaison between the Coding Department and the Clinical Documentation Specialist.
• Interacts with/educates physicians to enhance understanding of the CDI program.
• Facilitates performance improvement activities to achieve benchmark departmental and system metrics.
• Maintains compliance with all Orlando Health policies and procedures.

Benefits

• Competitive Pay
• Evening, nights, and weekend shift differentials offered for qualifying positions.
• All Inclusive Benefits starting day one.
• Student loan repayment and tuition reimbursement.
• FREE college education programs.
• Retirement savings.
• Paid paternity leave.
• Fertility benefits.
• Back up elder and childcare.
• Pet insurance.
• PTO/Holidays.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree