CDI Specialist

Thomas Jefferson University•Philadelphia, PA

3d•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 documentation opportunities and uses appropriate queries or communicates with physicians, coders, and other health team members to improve documentation. The role works independently, primarily in an approved remote home work environment. The specialist conducts concurrent medical-record reviews, supports regulatory and financial compliance, and helps ensure documentation accurately reflects diagnoses, procedures, comorbidities, complications, severity of illness, intensity of service, and risk of mortality. The role also collaborates with coding staff, educates physicians and other providers, tracks review activity and trends, and contributes to department improvement. The position requires maintaining professional credentials and continuing education as applicable.

Requirements

Bachelor of Science in Nursing, Bachelor of Science in Health Information Management or a related field, or an associate/bachelor’s degree or certification in another healthcare-related field with the specified experience.
Familiarity with computers and Microsoft Office applications.
Ability to work independently with minimal supervision.
Motivation, organization, strong interpersonal and analytical skills.
Ability to read and communicate in English.
Ability to lift and carry 25 pounds; frequent sitting or standing and frequent keyboard use.
Maintain appropriate registration or certification and track continuing education credits when applicable.

Nice To Haves

CCDS or CDIP certification preferred; eligible candidates must obtain CCDS within six months of hire.
RN/BSN preferred.
RHIA, or RHIT with CCS; MD or DO will also be considered.
Working knowledge of the Medicare reimbursement system and coding structures preferred.
Five years of critical care/emergency medicine 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.
Providers delivering patient care may need to perform role-specific activities including kneeling, bending, squatting, and CPR.

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 compliant, well-written queries for physicians and other providers to clarify missing or incomplete medical-record information.
Work with coding staff to ensure discharge diagnoses and co-existing comorbidities reflect the patient’s clinical status and care.
Educate attending physicians, residents, interns, nurse practitioners, and physician assistants; provide real-time intervention when needed to improve coding, regulatory compliance, and documentation.
Use computer applications including Epic EHR, 3M DRG, and Microsoft Office; meet productivity expectations and accurately record activity in CDI tracking software.
Apply 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 related to coding and CDI.
Identify process problems and suggest solutions; demonstrate initiative, judgment, and creative ability.
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 insurance
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, available to all colleagues, including per diem colleagues, adjunct faculty, and Jeff Temps