Clinical Documentation Integrity (CDI) Specialist

General Description: 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.

Essential 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.

General Responsibilities:

• Performs other duties as assigned

Minimum Qualifications:

Education: Associate's degree required, BS in Nursing or Registered Nurse preferred.

Experience: Five years acute care hospital experience or RHIA/RHIT/CCS with five years acute care inpatient coding experience required. 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.

License(s)/Certification(s)/Registration(s) Required: CCP, CCDS or CDIP preferred.

Knowledge, Skills and Abilities:

• Excellent verbal and written communication skills;
• Proficiency in organization and planning;
• Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and Internet searching;
• Understanding of organizational policies and procedures;
• Working knowledge of quality improvement theory and practice;
• Ability and willingness to seek out and accept change;
• Demonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice;
• Knowledge of federal, state and private payer regulations