Clinical Documentation Improvement Specialist
About The Position
The Clinical Documentation Improvement (CDI) Specialist educates providers and serves as the organization’s subject matter expert on provider documentation. The role advises providers on complete and accurate outpatient documentation and serves as a liaison between providers and coders, fostering mutual understanding of the uses of medical record documentation. Working independently, the specialist audits medical records to ensure complete and accurate provider documentation and coding. The role also requires building and maintaining collaborative relationships with providers and other stakeholders to support accurate documentation.
Requirements
- Hold at least one of the following certifications: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Coding Specialist Physician-Based (CCS-P), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), or Clinical Documentation Improvement Specialist (CDIS).
- Expert-level knowledge of and ability to apply medical documentation guidelines and practices.
- Knowledge of current coding guidelines and methodologies, including MS-DRG, APR-DRG, HCCs, and ICD-10-CM coding guidelines and conventions.
- Extensive knowledge of medical terminology, anatomy, pathophysiology, and ancillary test results.
- Excellent interpersonal skills for building and maintaining collaborative relationships.
Responsibilities
- Educate providers on topics related to provider documentation.
- Advise providers on complete and accurate outpatient documentation.
- Serve as a liaison between providers and coders to promote mutual understanding of medical record documentation.
- Independently audit medical records to ensure complete and accurate provider documentation and coding.
- Build and maintain collaborative relationships that support complete and accurate provider documentation.
Benefits
- Medical insurance
- Dental insurance
- Flexible Spending Account/Health Savings Account
- Life insurance, including company-paid life insurance
- Accident coverage
- Critical illness coverage
- Company-paid short-term disability
- Company-paid long-term disability
- Paid holidays
- Personal days
- Accrued paid time off, with 18 days in the first year
- Continuing medical education time and financial reimbursement
- Optional enrollment in the CCH 403(b) Retirement Plan, with employer match after one year of service
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
