Clinical Documentation Improvement Specialist - Clinical Document Improvement - Full Time 8 Hours Days (7:00AM to 5:30PM) (Non-Union, Non-Exempt)

University of Southern California

48d • $46 - $61 • Onsite

About The Position

The CDI Specialist is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the specificity of the physicians’ clinical documentation. This involves extensive record review, interaction with physicians, HIM professionals, and nursing staff. Involved with educational activities to maintain up-to-date information on Medicare, ICD-10, and CPT coding, and documentation guidelines. Active participation in team meetings by providing recommendations on query structure, process, and workflow. Responds to coding denials with clinical justifications and coding conventions. Maintain confidentiality of information acquired pertaining to patients, physicians, associates, and adheres to HIPAA regulations. Keep the CDI team and HIM Manager or Director informed of workflow status and potential backlog issues.

Requirements

• Graduate from a program of nursing, BSN, Health Information Management RHIT, RHIA, or foreign medical doctorate degree strongly preferred.
• Accredited college course work in human anatomy and/or physiology, medical terminology, and disease process is required.
• Competent with Windows based software programs.
• Extensive knowledge of ICD-10 CM and ICD-10-PCS coding, sequencing, and documentation guidelines skills and working knowledge of the AHA Coding Clinic preferred with experience in CPT/HCPCS for hospital and/or clinic records.
• Demonstrate critical thinking, problem solving and deductive reasoning skills.
• Demonstrate effective verbal and written communication skills.
• Extensive knowledge of Medicare Part A and how the regulatory requirements impact DRG assignments.
• Minimum of three years’ experience in clinical disciplines (RN, MD, FMG) or utilization review/case management in an acute care facility, with clinical knowledge.
• Strong background on pathophysiology and disease process.

Nice To Haves

• Certified Coding Specialist (CCS), Certified Coding Associate (CCA) or Certified Documentation Improvement Practitioner (CDIP) certification status preferred.
• Certified Clinical Documentation Specialist (CCDS) credential preferred.

Responsibilities

• Assist and develop tracking mechanisms to demonstrate program impact.
• Assist in the development plans for both formal and informal education for physicians, nursing, and other clinical staff.
• Meets established productivity targets for record review and appropriate query placement.
• Designs and implements in collaboration with physician leadership specific tools to support medical record physician documentation.
• Facilitates multidisciplinary team in efforts for clinical documentation improvement.
• Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
• Improve overall quality and completeness of clinical documentation in the medical record in accordance with all regulatory requirements.
• Reviews inpatient Medical Record for identified payor populations on admission and throughout hospitalization.
• Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation.
• Works collaboratively with coding staff to assure documentation of discharge diagnoses and any coexisting/comorbidities area complete reflection of the patient’s clinical status and care.
• Initiate appropriate clinical documentation querying to acquire or clarify necessary medical record documentation needed to facilitate accurate and complete coding.
• Able to compose coding appeals based on documentation, coding guidelines and Coding Clinic for coding denials and/or adjustments.
• Active participation in team meetings by providing recommendations on query structure, process, and workflow.
• Responds to coding denials with clinical justifications and coding conventions.
• Maintain confidentiality of information acquired pertaining to patients, physicians, associates, and adheres to HIPAA regulations.
• Keep the CDI team and HIM Manager or Director informed of workflow status and potential backlog issues.

Benefits

• excellent benefits and perks

What This Job Offers

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