Job Opening For Clinical Documentation Improvement (CDI) Specialist - PH/USRN

Clinical Documentation Improvement (CDI) specialists are responsible for improving the overall integrity of medical 
records documentation. 

Primary Roles Responsibilities

• Applying knowledge of medical terminology and procedures to evaluate clinical documents.
• Collecting medical information from healthcare providers and updating medical records.
• Verifying the accuracy of patient medical information and obtaining missing information.
• Facilitating and obtaining appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality.
• Interacting directly with physicians to query for more specific documentation and to provide documentation guidelines from ICD-9 and ICD-10 standards.
• Creating documentation education classes to general surgery residents, increasing the leveling of reporting which lead to increase revenues.
• Clinically evaluate how the health record translates into coded data, including review of provider and other clinician documentation, lab results, diagnostic information, and treatment plans.
• Communicate with providers either through discussion or in writing (e.g., formal queries) regarding missing, unclear, or conflicting health record documentation, and clarify the information as warranted.
• Educate providers about identification of disease processes that reflect SOI, complexity, and acuity to facilitate accurate application of code sets.
• Communicate with appropriate healthcare team members to promote accurate and complete documentation of diagnoses and/or procedures in the health record that have direct bearing on SOI.
• Demonstrate an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record, as well as the ability to impart this knowledge to providers and other members of the healthcare team.
• Gather and analyze information pertinent to documentation findings and outcomes and use this information to develop action plans for process improvements.
• Perform other duties as assigned.

Required Qualifications:

• Has active PH or US RN License
• Any RN minimum 1 year inpatient concurrent CDI experience
• Demonstrates effective verbal and written communication skills
• Knowledgeable in Microsoft Office