CDI Senior Specialist

JOB SUMMARY

Responsible for reviewing medical records to facilitate and obtain 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. This involves improving the quality of the physicians' clinical documentation by exhibiting a sufficient knowledge of clinical documentation requirements, MS-DRG Assignment, and clinical conditions or procedures.

ESSENTIAL DUTIES AND RESPONSIBILITIES

The CDI Specialist will perform the following duties:

• Record Review: Completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to evaluate documentation and assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality, and severity of illness. Initiates a review worksheet and conducts follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary.
• Professional Development: Stays current with AHA Official Coding and Reporting Guidelines, CMS, and other agency directives for ICD-9-CM and CPT coding. Attends mandatory coding seminars on an annual basis for inpatient and outpatient coding. Quarterly review of AHA Coding Clinic and attends quarterly coding updates and all coding conference calls as well as any required CDI education.
• CDI: Communicates/Completes Clinical Documentation Improvement (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolution.
• Other duties as assigned.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, the individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Displays teamwork and commitment while performing daily duties
• Demonstrates initiative and discipline in time management and medical record review
• Advanced knowledge of Medicare Part A and familiar with Medicare Part B
• Intermediate knowledge of disease pathophysiology and drug utilization
• Intermediate knowledge of MS-DRG classification and reimbursement structures
• Critical thinking, problem-solving, and deductive reasoning skills
• Effective written and verbal communication skills
• Knowledge of coding compliance and regulatory standards
• Excellent organizational skills for initiation and maintenance of efficient workflow
• Capacity to work independently in a virtual office setting or at a facility setting if required to travel for assignments
• Understands and communicates documentation strategies
• Recognizes opportunities for documentation improvement
• Formulates clinically compliant credible queries
• Ability to maintain an auditing and monitoring program as a means to measure query process
• Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation

EDUCATION / EXPERIENCE

The preferred candidate will have a graduate degree from a Health Information Management program (RHIT, RHIA, nursing degree, and/or bachelor's degree). Two or more years of relevant experience is also preferred.

CERTIFICATES, LICENSES, REGISTRATIONS

• Preferred: RHIT, RHIA, LPN, MD, AAPC, CCS
• Preferred: CDIP or CCDS

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Ability to sit for extended periods of time
• Must be able to efficiently use a computer keyboard and mouse
• Good visual acuity

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

OTHER

• May be required to travel nationally up to 10% of the time

This position requires a strong understanding of clinical documentation requirements, MS-DRG Assignment, and clinical conditions or procedures. The ideal candidate will have excellent communication and interpersonal skills, with the ability to work independently and as part of a team.