Clinical Documentation Integrity Specialist

The CDI Specialist performs concurrent inpatient chart reviews for documentation improvement opportunities. Communicates with physicians to ensure comprehensive medical record documentation to reflect clinical treatment and diagnose. Uses provided CDI software to identify opportunities, evaluate documentation, gather, and analyze information pertinent to findings and outcomes, formulated a DRG and confers with coders to ensure appropriate DRG assignment. This review process assures complete and accurate diagnostic and procedural coded data that supports compliant and accurate facility reimbursement, financial and strategic planning, outcome and statistical analyses, epidemiology/research work, and accurate reflection of patient mortality risk, severity of illness, quality of care, and patient safety measures.  

This position is eligible for benefits!

Some of the benefits we offer at Fairview include medical insurance - as low as $0, dental insurance - also a $0 option, PTO (24 days per year starting), and a 403B with up to a 6% employer match; visit www.fairview.org/benefits to learn more and get all the details.

• Completes daily concurrent reviews of the medical record to identify opportunities for clarification or improvement of the clinical documentation.  
• Identifies diagnoses and procedures codes to assign an accurate working DRG. 
• Performs follow-up medical record reviews to identify any additional diagnoses or procedures that may impact the DRG assignment. 
• Creates and sends compliant provider queries in accordance with ACDIS guidelines.
• Carries out follow-up practices related to provider query responses per department policy.
• Confers with coders to ensure appropriate final DRG and completeness of supporting documentation. Coordinates with coding to reconcile DRG mismatches.
• Collects and reports on data showing the activities performed, results of interactions, improvements made in clinical documentation, and distribution of DRGs and case mix index.
• Through chart review processes, ensures quality, patient safety indicators, present on admission indicators, risk of mortality, and severity of illness measures are clearly and accurately documented in the medical record.
• Effectively partners with stakeholders across the system including medical staff, quality, utilization review, and risk management.
• Adheres to ACDIS Code of Ethics, HIPAA, and official coding guidelines.
• Trains other staff as directed.

Organization Expectations, as applicable:  

• Fulfills all organizational requirements.
• Completes all required learning relevant to the role.
• Complies with and maintains knowledge of all relevant laws, regulation, policies, procedures, and standards.
• Fosters a culture of improvement, efficiency, and innovative thinking.
• Provides a remote workspace compliant with HIPAA guidelines.
• Performs other duties as assigned.

Required Qualifications

• Associates degree (or higher) in Nursing or Health Information Management (HIM) degree or related field or equivalent experience 
• 2 years Acute/Inpatient experience as an RN or 2 years of inpatient coding or CDI experience 
• One of the following: RHIA, RHIT, CCS, CPC, CPC, CCS, RN, CDIS, CDIP, CDEI, CCDS 

Preferred Qualifications

• Bachelor’s degree (or higher) in Nursing or HIM or related field or equivalent experience.  
• 5 years of acute/Inpatient care nursing or 5 years of inpatient coding or CDI experience
• One of the following: CDIS, CDIP, CDEI, CCDS

Additional Requirements: 

• Knowledge of clinical documentation requirements related to regulatory and reimbursement rules and regulations.
• Knowledge of medical terminology, anatomy and pathophysiology, pharmacology, ancillary test results.
• Knowledge of ICD-10-CM and DRG classification systems.
• Knowledge of physician and nursing unit practices.
• Excellent interpersonal, analytical critical thinking, problem solving and conflict management skills to foster a positive working environment.
• Excellent verbal and written communication skills.
• Builds effective partnerships with other coding and documentation staff, ancillary staff, and medical providers, fostering open lines of communications and establishing trust.
• Responsible for following all coding, payer, and regulatory guidelines for compliant and accurate code assignment.
• Uses denials information and trends to improve documentation capture at the point of care.
• Proficiency in computer skills, including Microsoft products (i.e. Teams, Word, Excel, Outlook), EPIC, and other programs, as assigned.
• Ability to work independently, self-motivate, and adapt to change.
• Attention to detail: Achieve thoroughness and accuracy when accomplishing a task.