The Clinical Documentation Improvement Specialists (CDI) reports to the Director of HIM. They will provide concurrent review of clinical documentation in the medical record by a thorough chart review to identify severity, comorbidities, complications, working DRG’s and procedures. They will work collaboratively with the medical staff, providers and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality. Collaborate with physicians, physician extenders, nurses, case managers and Medical Record coders to identify principal diagnosis options, secondary diagnoses, procedures, assign working DRGs and identify educational opportunities. CDI is able to identify and communicate areas of focus through report analysis.
Experience and Qualifications:
REQUIRED: RN or CDIP or CCDS. At least two - five years’ experience in an inpatient setting and working with CMS regulatory requirements’. Experience with ICD-10 CM, MS-DRGs and documentation guidelines. Excellent problem solving skills, the ability to work independently, and to perform under pressure in a positive, teamwork manner with diplomacy and tact. Interpersonal verbal and written communication skills to accurately relay information to staff and to internal and external customers. Proficient computer skills and Microsoft Office
Licensure/Registration and/or Certification:
Required RN, or CCDS or CDIP