What are the responsibilities and job description for the CDI Specialist position at medstar?
Ensures that documentation supports accurate, complete and consistent, unambiguous clinical documentation. Utilizes clinical expertise to support appropriate reflection of the patient's risk of mortality and severity of illness. Develops compliant physician queries guided by the American Health Information Management Associations (AHIMA) Ethical Standards for Clinical Documentation Improvement Professionals, the ACDIS/AHIMA Query practice brief, and state, federal, and other appropriate regulatory guidance. Evaluates the medical records for case specific review including mortalities, complications, quality of care, and other needs identified requiring review and/or second level review. Reviews and analyzes inpatient record for compliant documentation. Provides education to all levels of clinical staff. Closely collaborates with coding professionals to ensure appropriate ICD-10 and DRG assignment. Maintains certification and credentials applicable to the Clinical Documentation Integrity Specialist role. Monitors clinical case data to identify areas of improvement.
