CDI Specialist-Inpt

WVU Medicine

About The Position

Facilitates improvement in the overall quality and completeness of clinical documentation to assure accurate coding assignment, severity of illness and risk of mortality through extensive interaction with, and education of, providers and multidisciplinary team members. May perform at a level requiring continued feedback and monitoring or mentoring

Requirements

Must have one of the following qualifications: High School Diploma or Equivalent AND Graduate of Health Information Technology (HIT) or equivalent program with RHIT (Registered Health Information Technician) or RHIA (Registered Health Information Administrator) AND Three (3) years outpatient/ambulatory or inpatient acute care coding OR; Current West Virginia Licensed Registered RN (RN) AND Three (3) years clinical experience in outpatient/ambulatory or inpatient acute care setting OR; Current West Virginia Licensed Practical Nurse (LPN) AND Four (4) of clinical experience in outpatient/ambulatory or inpatient acute care setting OR; High School Diploma or Equivalent AND CCS (Certified Coding Specialist) AND Three (3) years of outpatient/ambulatory or inpatient acute care setting OR; One of the above credentials AND Two (2) years of CDI experience OR; High school diploma or equivalent AND Five (5) years of CDI experience in the inpatient acute care setting.
Must possess excellent written and verbal communication skills, as well as interpersonal skills necessary to communicate effectively.
Must possess the knowledge of related provider healthcare compliance, revenue cycle operations, and auditing techniques required.
Must possess the ability to accept mentoring, education and training from others.
Must meet quality and productivity standards.
Must be able to concentrate and maintain accuracy during constant interruptions.
Must possess the ability to prioritize job duties.
Must be able to adapt to changes in the workplace and work assignments.
Must possess organizational and time management skills.
Must possess the knowledge of anatomy, physiology and medical terminology.
Must possess analytical and problem solving skills.
Must be proficient in office software programs.
Must be able to work independently with minimal supervision.

Nice To Haves

Experience in Risk Adjusted Coding or Evaluation and Management highly desirable.

Responsibilities

In collaboration with the providers and staff, identifies and records principle diagnoses, secondary diagnoses, procedures, and assigns a working Diagnostic Related Group (DRG).
Conducts initial concurrent review and ongoing re-reviews for all selected admissions by documenting findings regarding DRGs, APR-DRGs and Value Based Purchasing/Quality measures.
Identifies need to clarify documentation through quality audits in records and initiates communication with physician, nurse, or patient care coordinator by utilizing the appropriate “query” tools in order to capture the documentation in the medical record that accurately supports the patient’s severity of illness.
Provides information and ongoing education as necessary to providers and staff on documentation issues, guidelines, and unanswered queries.
Promotes compliance with CMS, Medicare documentation, and coding and billing regulations.
Participates in the processes to assess and improve the services provided and compliance with regulatory requirements. Reports results assessment and improvement processes to the appropriate administrative levels.
Collaborates with the Quality Department to ensure documentation meets quality initiative standards used for measuring and reporting hospital and provider outcomes.
Collects, analyzes and submits timely, accurate and complete reports of clinical documentation information used for measuring and reporting Hospital and Provider outcomes data.
Facilitates in the education and training of new associates concerning clinical documentation improvement guidelines and processes. This may include providers, CDIs, coders, and other healthcare providers.
Works with the Coding Specialists on any issues that arise concerning documentation, providers, and queries to enhance the concurrent process to enable prompt coding.
May provide educational support in terms of clinical/coding or process at manager’s discretion and as need arises.