Clinical Documentation Integrity (CDI) Specialist
About The Position
This position follows a hybrid schedule with four in-office days per week. Primary Responsibilities: Perform concurrent and retrospective chart reviews for improving the overall completeness of clinical documentation. Keep abreast of current coding trends and maintains up to date knowledge of Medicare rules and regulations regarding diagnosis coding and CDI trends. Effectively utilizes ICD-10 and related materials to investigate coding issues and produce accurate results. Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity. Provides expert level leadership for overall improvement in clinical documentation by providing proficient review and assessment, and effectively articulating recommendations for improvement including the rationale for the recommendations. Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality. Provides complete follow through on all requests for clarification or recommendations for improvement. Ensures effective utilization of Technology to document all clarification activity. Collaborates closely with interfacing departments such as Care Coordination and Quality. Utilizes only the Optum/client approved clarification forms. Proactively develops a reciprocal relationship with the HIM Coding Professionals. Engages and consults with Physician Advisor/CMO when needed, per the hospital defined escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation integrity process. You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Requirements
- Undergraduate degree or equivalent experience.
- 5+ years acute care hospital clinical RN experience OR Medical Graduate with CDI experience
- Advanced proficiency in clinical medicine, pathophysiology, and pharmacology
- Advanced proficiency communicating & working closely with Physicians
- Intermediate proficiency using a PC in a Windows environment, including Microsoft Word, Excel, Power Point and Electronic Medical Records
Nice To Haves
- Experience interacting with Providers providing concurrent/chart review
- Proven comfortable with technology
Responsibilities
- Perform concurrent and retrospective chart reviews for improving the overall completeness of clinical documentation
- Keep abreast of current coding trends and maintains up to date knowledge of Medicare rules and regulations regarding diagnosis coding and CDI trends
- Effectively utilizes ICD-10 and related materials to investigate coding issues and produce accurate results
- Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity
- Provides expert level leadership for overall improvement in clinical documentation by providing proficient review and assessment, and effectively articulating recommendations for improvement including the rationale for the recommendations
- Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality
- Provides complete follow through on all requests for clarification or recommendations for improvement
- Ensures effective utilization of Technology to document all clarification activity
- Collaborates closely with interfacing departments such as Care Coordination and Quality
- Utilizes only the Optum/client approved clarification forms
- Proactively develops a reciprocal relationship with the HIM Coding Professionals
- Engages and consults with Physician Advisor/CMO when needed, per the hospital defined escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation integrity process
Benefits
- comprehensive benefits package
- incentive and recognition programs
- equity stock purchase
- 401k contribution
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What This Job Offers
Job Type
Full-time
Career Level
Senior
