CDI Specialist

Jefferson Health Plans • Philadelphia, PA

4d • Remote

About The Position

Under the direction of the CDI Manager, the Clinical Documentation Specialist reviews medical records to facilitate accurate and complete documentation of clinical treatment, decisions, and diagnoses used to measure and report hospital and physician outcomes. The specialist identifies opportunities for additional documentation and places appropriate queries or communicates with physicians, coders, and other health team members to improve documentation. The position works independently and primarily in an approved remote home work environment.

The role supports compliant documentation of diagnoses, procedures, comorbidities, and complications; accurate severity-of-illness, intensity-of-service, and risk-of-mortality classifications; and designated quality reviews. It includes concurrent record reviews, provider education, collaboration with coding staff, tracking and trending issues, and ongoing professional development related to coding and CDI practices.

Requirements

• Bachelor of Science in Nursing; Bachelor of Science in Health Information Management or a related field; or certification, associate degree, or bachelor's degree in another health care-related field with the specified experience.
• Ability to read and communicate in English.
• Familiarity with computers and Microsoft Office applications.
• Ability to work independently with minimal supervision.
• Motivated and organized, with strong interpersonal and analytical skills.
• Maintain appropriate registration or certification and track continuing education credits as applicable.
• CCDS certification within six months of hire for eligible candidates.

Nice To Haves

• CCDS or CDIP certification preferred.
• RN/BSN preferred.
• RHIA, or RHIT with CCS, MD, or DO, will be considered.
• Working knowledge of the Medicare reimbursement system and coding structures preferred.
• Five years of critical care/emergency medicine experience or five years of medical-surgical experience preferred.
• Two to three years of Clinical Documentation Improvement experience or five years of coding experience preferred.
• MD/DO candidates with two years of experience as a concurrent or retrospective coder or documentation specialist in an inpatient acute care facility using the United States IPPS system will be considered.
• Strong facilitation and presentation skills preferred.

Responsibilities

• Review medical records concurrently for complete diagnostic and procedural documentation and compliance with CMS, DOH regulatory, and financial requirements.
• Ensure diagnoses, procedures, comorbidities, and complications are documented to support severity-of-illness, intensity-of-service, risk-of-mortality classifications, and quality reviews such as Patient Safety Indicator reviews.
• Prepare clear, compliant queries for physicians and other providers to obtain missing, incomplete, or clarifying medical record information.
• Work with coding staff to ensure discharge diagnoses and coexisting comorbidities accurately reflect the patient's clinical status and care.
• Interact with and educate attending physicians, residents, interns, nurse practitioners, and physician assistants; provide timely intervention and education about coding, regulatory compliance, and documentation deficiencies.
• Use computer applications including Epic EHR, 3M DRG, and Microsoft Office.
• Meet productivity expectations and accurately record activity in the CDI software tracking tool.
• Apply working knowledge of HIPAA, protected health information, and laws governing access to PHI.
• Work independently in a remote home environment and troubleshoot systems issues in accordance with department policies and procedures.
• Review medical records for other applicable regulatory requirements.
• Track and trend issues identified during concurrent reviews; attend department meetings and contribute to department and hospital improvement.
• Attend continuing education meetings, in-services, training sessions, and audioconferences to maintain skills and stay current with coding guidelines and CDI best practices.
• Demonstrate initiative, judgment, and creativity; identify process problems and suggest solutions.
• Perform other duties and assignments as necessary.

Benefits

• Medical insurance, including prescription coverage
• Supplemental insurance
• Dental insurance
• Vision insurance
• Life and AD&D insurance
• Short- and long-term disability
• Flexible spending accounts
• Retirement plans
• Tuition assistance
• Voluntary benefits, including access to group insurance rates and discounts
• Tuition discounts at Thomas Jefferson University after one year of full-time service or two years of part-time service
• Medical insurance, including prescription coverage, is available to all colleagues, including those working less than part-time

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level