CDI Specialist Job Description
The CDI Specialists will work remotely and perform concurrent reviews and post-discharge reviews of targeted inpatient medical records for complete, accurate documentation. The CDI Specialist’s responsibilities will include:
Conducting initial and secondary concurrent reviews as needed on selected admissions and document findings;
Assigning principal diagnosis, secondary diagnosis(es), identifying all CC/MCC, evaluating for severity of illness (“SOI”) and risk-of-mortality (“ROM”) on all patients;
identifying, flagging, and escalating cases with Patient Safety Indicators (“PSI” 90) and Hospital Acquired Conditions (“HAC”) in the system;
Conducting an ongoing thorough review of designated medical record documentation to identify and record all conditions currently being evaluated, monitored, or treated;
Completing initial patient reviews, conducting subsequent reviews of patient records, and entering findings in the software system;
Assisting in establishing criteria for prioritization of cases;
Communicating with the medical staff and other caregivers as necessary via written/verbal methods to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality while adhering to:
identification of clinical indicators as the foundation of all communication to providers for documentation clarification or request for specificity; and,
AHIMA Standards of Ethical Coding as it relates to the need to obtain from the provider clarification of incomplete, conflicting, or ambiguous documentation regarding a reportable condition or procedure or other reportable data element (e.g., present on admission indicator).
Supporting hospital goals and objectives for compliant clinical physician documentation professionally and courteously;
Adhering to written hospital policies and procedures related to documentation of clinical conditions queries the treatment team as necessary via written/verbal communication to obtain accurate and complete documentation;
Applying knowledge of official coding guidelines, Coding Clinic advice, and regulatory requirements to improve the quality of documentation;
Utilizing the Client’s electronic medical record that includes CDI review, data entry, reporting, and query tracking;
Understanding and supporting CDI documentation strategies and continuing to self-educate by attending available education sessions and using educational tools; and,
Willing to obtain relevant certifications within 12 months
Requirements:
Must have experience in handling acute trauma or experience in ER
At least 3 years of acute trauma or 1 to 2 years in ER
Who can Apply
RNs and MDs with or without CDI experience