CDI - Inpatient Onsite
The Clinical Documentation Integrity (CDI) Specialist is accountable for reviewing patient medical records in the inpatient ICU Neuro and Neurosurgery setting to capture accurate representation of the severity of illness and facilitate proper coding. The CDI Specialist validates that coding reflects medical necessity of services and facilitates appropriate coding which provides an accurate reflection and reporting of the severity of the patient's illness along with expected risk of mortality and complexity of care.
Documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care. Utilizes advanced knowledge of disease processes (pathophysiology), medications, and have critical thinking skills to analyze current documentation to identify gaps. Identifies opportunities in concurrent and retrospective inpatient clinical medical documentation to support quality and effective coding. Understands and applies regulatory compliance related to documentation, coding and billing for all health insurance plans.
The CDI Specialist facilitates appropriate modifications to documentation through extensive interactions and collaboration with physicians, coding, case management, nursing and other care givers. Serves as an effective change agent as an educator and resource for physicians and allied health staff to improve the quality and completeness of the clinical documentation. Performs all duties and responsibilities in accordance with ethical and legal business procedures, compliant with federal and state statutes and regulations, official coding rules, guidelines and accepted standards of coding practice including appropriate clinical documentation policies.
- Complies with hospital, department, and unit standards, including but not limited to safety, infection control, quality management, environmental, confidentiality, and patient care.
- Prioritizes work and provides prompt and efficient service.
- Improves the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation guidelines.
- Educates all internal customers, including physicians, on clinical documentation opportunities and coding and reimbursement issues and quality and medical necessity documentation compliance.
- Assists medical and other patient care staff to identify the most accurate principal diagnosis and secondary diagnoses and chief complaint to accurately reflect severity of illness and risk of mortality in compliance with applicable payer requirement and government regulations.
- Confers with physicians to clarify information, obtain needed documentation, present education regarding the significant of appropriate documentation needed to support clinical severity and accurate coding.
- Conducts follow-up concurrent and retrospective medical record review to ensure that agreed-upon information has been included in medical record documentation.
- Confers with coding specialist and clinicians to ensure appropriate reimbursement for the level of service rendered to all patients with DRG based payers. Ensures the clinical information utilized in profiling and reporting outcomes is complete and accurate.
- Demonstrates competency in selected administrative skills. Includes but not limited to:
- Performs chart and/or data abstract reviews.
- Conducts concurrent review of CMSDNV measures and optimum DRG documentation.
- Working knowledge of ICD-10 coding/DRG assignment is required
- Interfaces with physicians for documentation clarification.
- Enters results of concurrent and retrospective reviews in computerized tracking and reporting system.
- Edits, complies and assists in analyzing data for studies, audits and other reports.
- Assists in training new personnel.
- Assist with care and maintenance of department equipment and supplies.
- Maintains department records, reports, and files as required.
- Demonstrates responsibility and accountability for own performance on team in regards to:
- Attendance and punctuality.
- Positive public relations image and working relationships.
- Obtaining necessary knowledge and skill needed to maintain competence.
- Completing all mandatory requirements.
- Participates in the development and attainment of team, department and hospital goals including:
- Attending and participating in team meetings.
- Volunteering or accepting assignments for projects.
- Mission, vision, and team ground rules.
- Performs other related duties as assigned or requested.
- Complies with hospital, department, and unit standards, including but not limited to safety, infection control, quality management, environmental, confidentiality, and patient care
- Prioritizes work and provides prompt and efficient service.
- Educates all internal customers, including physicians, on clinical documentation opportunities and coding and reimbursements issues and JCAHO/CMS measure compliance.
- Assists physicians and other care givers in the identification of the most appropriate principal diagnosis and chief complaint to accurately reflect severity of illness in compliance with applicable payer requirement and government regulations.
- Confers with physicians to clarify information, obtain needed documentation, present education regarding the significant of appropriate documentation needed to support clinical severity and accurate coding and JCAHO/CMS measure compliance.
• At least 3 to 5 years inpatient CDI review experience including ICU Neuro and Neurosurgery.
• At least 7 years of related experience is preferred.
• Four-year Bachelor's degree or equivalent experience is required BSN or RHIA
• Graduate or professional work or advanced degree; or equivalent experience is preferred
Licenses & Certifications:
- RN Required
- CCDS or CDIP preferred
- CRC or CCS is preferred but not required
· Salary Range: $93,000 to 104,000 per year
· Paid Time Off
· Sick Time
· Medical, Dental, Life and Long/Short term disability Insurance.
· Paid Association Dues Paid
· Educational Benefits
Revenue Cycle Solutions formerly MedPartners and Peak and Peak offers opportunities for learning and career development; competitive pay; and a comprehensive benefits program.
We promote a diverse and inclusive workplace. Our team members have a voice in their work through surveys, pulses and town halls.
At Revenue Cycle Solutions, we value the role each team member plays in helping us deliver on our mission of making life better for our healthcare facilities. We take pride in providing a rich and rewarding career opportunities that enable team members to reach their highest potential.
We invite you to learn more about Revenue Cycle Solutions.
Apply Today and a team member will contact you shortly to discuss this opportunity further.