Clinical Document Specialist (CDI)

Description

The CDI Specialist is responsible for facilitating modifications to clinical documentation through pre-bill interaction with providers and other members of the heath care team. The CDI Specialist captures clinical severity to support the level of service provided to current patient populations.

ESSENTIAL/PRIMARY JOB SPECIFIC RESPONSIBILITIES:
General Responsibilities:
• Clinically evaluate how the health record translates into coded data, including review of provider and other clinician documentation, lab results, diagnostic information, and treatment plans
• Communicate with providers either through discussion or in writing (e.g., formal queries) regarding missing, unclear, or conflicting health record documentation, and clarify the information as warranted
• Educate providers about identification of disease processes that reflect SOI, complexity, and acuity in order to facilitate accurate application of code sets
• Communicate with appropriate healthcare team members to promote accurate and complete documentation of diagnoses and/or procedures in the health record that have direct bearing on SOI
• Demonstrate an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record, as well as the ability to impart this knowledge to providers and other members of the healthcare team
• Gather and analyze information pertinent to documentation findings and outcomes, and use this information to develop action plans for process improvements
• Review inpatient medical records on a daily basis, concurrent with patient stay, to identify opportunities to clarify missing or incomplete documentation.
• Collaborate with providers, case managers, coders, and other healthcare team members to facilitate comprehensive health record documentation that reflects clinical treatment, decisions, diagnoses, and interventions.
• Utilize the hospital’s designated clinical documentation system to conduct reviews of the health record and identify opportunities for clarification.
• Conduct follow-up of posted queries to ensure that queries have been answered and physician responses have been appropriately documented.
• Provide or coordinate education related to compliance, coding, and clinical documentation issues within the healthcare organization.
• Clinically evaluate how the health records translate into coded data.
• Manage all electronic clinical documentation in the hospital.
• Communicate with providers regarding missing, unclear, or conflicting health record documentation to provide accurate information.
• Communicate with appropriate healthcare team members to promote accurate health record documentation of diagnoses and/or procedures.
• Demonstrate an understanding of diagnoses
• Performs other duties as assigned.

 

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Job Requirements

Experience

EXPERIENCE:
• 5+ years needed as an inpatient acute care or long-term acute care coder or

Education Required

Associate degree in Health Information management preferred.

Additional Information

LICENSURE/CERTIFICATION:
• Certified Clinical Documentation Specialist (CCDS) preferred
• Certified Coding Specialist credentials or work experience equivalent