CDI Specialist

AHMC Healthcare • Riverside, CA

11d • Onsite

About The Position

Clinical Documentation Improvement (CDI) Specialist will provide active concurrent/retrospective review of inpatient medical records, provide feedback and educate clinical care providers to improve the documentation of all conditions, treatments and care plans within the health record to accurately reflect the condition of the patient and promote patient care. In addition, documentation should reflect documentation associated with MS-DRG assignment, case mix index, severity of illness, risk of mortality, physician profiling, and hospital profiling and reimbursement rules. In this role, you will facilitate improvement in medical record documentation by interacting with and educating physicians, nurses and coding staff to ensure medical records accurately reflect patient acuity for quality reporting and reimbursement. The ideal candidate will thrive in a fast-paced environment, with high physician and coding staff interaction.

Requirements

• CCS AHIMA certification required.
• ACDIS CDI certification or AHIMA CDIP certification required.
• At least 2 years experience as CDI-S in acute clinical environment (not remote) required.
• Strong clinical knowledge and demonstrated commitment to maintaining relevancy in clinical field.
• Familiarity with ICD-10-CM Official Coding Guidelines.
• Excellent written and verbal communication skills.
• Excellent critical thinking skills.
• Excellent listening skills.
• Excellent interpersonal skills to build effective partnering relationships with physicians, care management team, nursing staff, coding staff and other hospital staff.
• Ability to work independently in a time oriented environment.
• Ability to analyze problems and issues from a variety of perspectives and understand the legal, reimbursement and impact.

Responsibilities

• Provide active concurrent/retrospective review of inpatient medical records.
• Provide feedback and educate clinical care providers to improve the documentation of all conditions, treatments and care plans within the health record.
• Ensure documentation accurately reflects the condition of the patient and promotes patient care.
• Ensure documentation reflects documentation associated with MS-DRG assignment, case mix index, severity of illness, risk of mortality, physician profiling, and hospital profiling and reimbursement rules.
• Facilitate improvement in medical record documentation by interacting with and educating physicians, nurses and coding staff.
• Ensure medical records accurately reflect patient acuity for quality reporting and reimbursement.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed