Clinical Documentation Integrity Specialist (CDI)

Responsibilities:

Under the direction of CDI Manager, the Clinical Documentation Specialist reviews medical records to facilitate accurate and complete medical record documentation to reflect clinical treatment, decisions, and diagnoses used for measuring and reporting hospital and physician outcomes
Accurately identifies additional documentation opportunities and places appropriate queries and/or communicates with physicians, coders, and other health team members (i.e., PI, Case managers, Nurse Navigators, etc.) for documentation improvement
Works independently in an approved, remote home environment and effectively troubleshoots system issues in accordance with Department policy and procedures
Accurately reviews medical records concurrently/retrospectively for completeness in documentation of diagnostic and procedural information for compliance to CMS, DOH regulatory, and financial requirements
Assures documentation of diagnoses, procedures, co-morbid, and complication conditions are reflected on the medical record to support proper severity of illness (SOI), intensity of service, and risk of mortality (ROM) classifications and designated quality reviews (i.e., Patient Safety Indicator reviews)
Prepare well written and compliant queries to communicate with physicians and other providers regarding missing, incomplete or clarifying information needed in the medical record
Works closely with coding staff to assure that documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care
Interacts and continuously educates physicians (attendings, residents and interns), nurse practitioners and physician assistants
Provides real-time intervention/education when needed to promote correct coding, regulatory compliance, and correction of documentation deficiencies
Interacts with co-workers, visitors, and other staff consistent with the values of CRS.
Maintains productivity expectations
Accurately records activity in CDI software tracking tool
Tracks and trends issues identified during concurrent reviews
Attends department meetings
Actively contributes to the continued improvement and success of the department and the hospital
Attends continuing education meetings, in-services, and training sessions and audioconferences related to coding and CDI to maintain skills and stay abreast of coding guideline changes and best practice CDI processes
Demonstrates initiative, judgement and creative ability in performance of job duties
Identifies problems with processes and suggests possible solutions
Functions in a professional, efficient and positive manner
Performs other duties and assignments, as necessary
Responsible for tracking Continuing Education credits to maintain professional credentials if applicable