CDI Specialist

Jefferson Health Plans•Philadelphia, PA

2d•Remote

About The Position

Under the direction of the CDI Manager, the Clinical Documentation Specialist reviews medical records to ensure accurate and complete documentation that reflects clinical treatment, decisions, and diagnoses. This role is crucial for measuring and reporting hospital and physician outcomes. The specialist identifies documentation improvement opportunities, places appropriate queries, and communicates with physicians, coders, and other health team members. This position primarily operates in an approved remote home work environment and requires the ability to work independently.

Requirements

Bachelor of Science in Nursing, Bachelor of Science in Health Information Management or related field. OR Certification, Associate or Bachelor in other healthcare related field with experience noted below.
Expert working knowledge of HIPPA PHI and all laws relative to access PHI (protected Health Information).
Competent in utilizing all computer applications, e.g.; Epic EHR, 3M DRG, MS Office.
Ability to work independently with minimal supervision.
Motivated, organized with excellent Interpersonal skills, analytical skills.
Ability to read and communicate in the English Language.

Nice To Haves

CCDS, CDIP certification preferred.
RN/BSN preferred.
RHIA, or RHIT with CCS, MD or DO will be considered.
CCDS within 6 months of hire for eligible candidates.
Working knowledge of Medicare reimbursement system and coding structures preferred.
5 years of Critical Care/Emergency medicine or 5 years of Medical Surgical Experience preferred.
2-3 years Clinical Documentation Improvement experience or 5 years of Coding experience preferred.
MD/DO with two years of experience as a concurrent or retrospective coder or documentation specialist in an inpatient acute care facility using the United States IPPS system will be considered.
Familiarity with computers and Microsoft Office applications required.
Strong facilitation and presentation skills preferred.

Responsibilities

Accurately review medical records concurrently for completeness in documentation of diagnostic and procedural information for compliance to CMS, DOH regulatory, and financial requirements.
Assure documentation of diagnoses, procedures, co-morbid, and complication conditions are reflected on the medical record to support proper severity of illness, intensity of service, and risk of mortality classifications and designated quality reviews.
Prepare well-written and compliant queries to communicate with physicians and other providers regarding missing, incomplete, or clarifying information needed in the medical record.
Work closely with coding staff to assure that documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care.
Interact with and continuously educate physicians (attending’s, residents and interns), nurse practitioners, and physician assistants.
Provide real-time intervention/education when needed to promote correct coding, regulatory compliance, and correction of documentation deficiencies.
Maintain productivity expectations and accurately record activity in the CDI software tracking tool.
Demonstrate working effectively and independently in a remote home work environment, and effectively troubleshoot systems issues in accordance with department policy and procedures.
Review medical record for other identified regulatory requirements as applicable.
Track and trend issues identified during concurrent reviews.
Actively contribute to the continued improvement and success of the department and the hospital.
Attend continuing education meetings, in-services, and training sessions and audioconferences related to coding and CDI to maintain skills and stay abreast of coding guideline changes and best practice CDI processes.
Identify problems with process and suggest possible solutions.
Perform other duties and assignments as necessary.

Benefits

Medical (including prescription)
Supplemental insurance
Dental
Vision
Life and AD&D insurance
Short- and long-term disability
Flexible spending accounts
Retirement plans
Tuition assistance
Voluntary benefits (group rates on insurance and discounts)
Tuition discounts at Thomas Jefferson University after one year of full-time service or two years of part-time service.