Clinical Documentation Improvement (CDI) Specialist

Tampa General Hospital • Tampa, FL

124d

About The Position

The position facilitates clinical documentation improvement through the identification of documentation issues. The role involves extensive day-to-day interaction with providers, other patient caregivers, coding staff, and Care Coordinators. Responsibilities include collecting and analyzing data and reports, as well as developing, coordinating, and/or providing education regarding documentation opportunities. The individual will review the quality of documentation in the patient medical record to enhance the quality of care, ensure accurate data reporting to regulatory agencies, and facilitate appropriate reimbursement. Collaboration with the coding team is essential to promote accurate patient diagnostic and procedural information in the medical record and final DRG assignment.

Requirements

• Registered Nurse (RN) with a valid Florida license and at least 5 years of acute care clinical experience OR a Health Information Management (HIM) degree with commensurate Clinical Documentation Improvement (CDI) experience.
• Strong written and oral communication skills.
• Computer literacy.
• Familiarity with MSDRGs, APR DRGs, and coding guidelines.
• Understanding of DRG assignment and its impact on quality metrics and ratings.

Responsibilities

• Facilitate clinical documentation improvement by identifying documentation issues.
• Interact daily with providers, patient caregivers, coding staff, and Care Coordinators.
• Collect and analyze data and reports related to clinical documentation.
• Develop, coordinate, and provide education on documentation opportunities.
• Review the quality of documentation in patient medical records to enhance care quality.
• Ensure accurate data reporting to regulatory agencies and appropriate reimbursement.
• Collaborate with the coding team to promote accurate patient diagnostic and procedural information.

What This Job Offers

• Career Level: Mid Level
• Education Level: Bachelor's degree