Clinical Documentation Integrity (CDI) Specialist

OU Health•WFH State of Oklahoma, OK

1d•Remote

About The Position

The Clinical Documentation Integrity (CDI) Specialist conducts concurrent review of the clinical documentation in the medical record to achieve more accurate and detailed documentation. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient which will in turn improve the quality of patient care, more accurately portray the facility's quality outcomes ratings, reduce compliance risks, and capture appropriate reimbursement.

Requirements

Associate’s degree required
Five years acute care hospital experience or RHIA/RHIT/CCS with five years acute care inpatient coding experience required.

Nice To Haves

BS in Nursing or Registered Nurse preferred.
Licensed healthcare experience (RN, LPN, CRT/RRT) or completion of medical school preferred.
Advanced clinical expertise and/or extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting preferred.
CCP, CCDS or CDIP preferred.

Responsibilities

Provides daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans.
Responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures.
Communicates with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness.
Communicates with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record.
Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team.
Gathers and analyzes information pertinent to documentation findings and outcomes.