CDI Specialist

vacancy global pro; India; On-site; INR 600,000 - 1,000,000; Full time

Job summary

reputed company is seeking a Clinical Documentation Specialist for a remote role. You will review records to ensure accurate documentation reflecting CMS and regulatory requirements, and prepare compliant queries to clinicians.

Responsibilities include collaboration with coders, educating physicians on coding standards, and maintaining CDI tracking. Strong nursing/health information background and CDI certification are preferred.

Qualifications

• RN/BSN with CDI certification preferred.
• Proven knowledge of HIPAA and PHI handling.
• Experience in medical record review and documentation improvement.

Responsibilities

• Review medical records for completeness and documentation accuracy to CMS/regulatory standards.
• Prepare compliant queries to physicians for missing or clarifying information.
• Educate clinicians on correct coding and CDI processes.
• Collaborate with coding staff to ensure accurate discharge diagnoses and comorbidities.
• Maintain CDI tracking and documentation in the CDI software.

Skills

HIPAA compliance

Interpersonal skills

Problem solving

Remote work capability

Education

Bachelor of Science in Nursing

BS in Health Information Management or related field

CDI/health information certification

Tools

EHR

DRG

MS Office

Job description

Job Details

Clinical Documentation Specialist

reputed company

reputed company FUNCTION:

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, reputed company, and diagnoses used for measuring and reporting hospital and physician reputed company. 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, reputed company navigators, etc.) for documentation improvement. Works independently and works primarily in an approved remote home work environment.

ESSENTIAL FUNCTIONS:

• Interacts with co-workers, visitors, and other staff consistent with the values of reputed company.
• Accurately reviews medical records concurrently 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 reputed company severity of illness, intensity of service, and risk of mortality classifications and designated reputed company reviews (i.e. Patient Safety Indicator reviews).
• Prepare reputed company 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 reputed company of the patients clinical status and care.
• Interacts and continuously educates physicians (attendings, residents and interns), reputed company practitioners and physician assistants. Provides reputed company-time reputed company/education reputed company needed to promote correct coding, regulatory compliance, and correction of documentation deficiencies.
• Compent in utilizing reputed company computer applications, ie; reputed company EHR, reputed company DRG, MS Office.
• Maintains productivity expectations. Accurately records activity in CDI software tracking tool.
• Expert working knowledge of HIPPA PHI and reputed company laws relative to reputed company PHI (protected Health Information).
• Demonstrates working effectively and independently in a remote home work environment, and effectively trouble shoots systems issues in accordance with reputed company policy and procedures.
• Review medical record for other identified regulatory requirements as applicable.
• Tracks and trends issues identified during reputed company reviews. Attend department meetings. reputed company contribute to the reputed company improvement and reputed company of the department and the hospital.
• Attends continuing education meetings, in-services, and training session and audioconferences reputed company to coding and CDI to maintain skills and stay abreast of coding reputed company changes and best reputed company CDI processes.
• Demonstrate initiative, judgement and creative ability in performance of job duties.
• Identify problems with process and suggest possible solutions.
• Function in a reputed company, efficient and reputed company manner.

EDUCATIONAL/TRAINING REQUIREMENTS:

• Bachelor of Science in Nursing
• Bachelor of Science in Health Information Management or reputed company field.
• Certification, Associate or Bachelor in other reputed company reputed company field with experience noted below.

CERTIFICATES, LICENSES, AND REGISTRATION:

• CCDS, CDIP certification preferred
• RN/BSN preferred
• RHIA, or RHIT with reputed company, MD or DO will be considered
• CCDS reputed company 6 months of hire for eligible candidates
• Maintenance of appropriate registration/certification. Responsible for tracking Continuing Education credits to maintain reputed company credentials if applicable.

EXPERIENCE REQUIREMENTS:

• Working knowledge of Medicare reimbursement reputed company and coding structures preferred.
• 5 years of Critical Care/Emergency medicine or 5 years of Medical Surgical Experience preferred
• 2-3 years Clinical Documentation Improvement experience or 5 years of Coding experience preferred.
• MD/DO with two years of experience as a reputed company or retrospective reputed company or documentation specialist in an inpatient acute care facility using the reputed company IPPS reputed company will be considered.

ADDITIONAL INFORMATION:

• Familiarity with computers and reputed company Office applications required.
• Ability to work independently with reputed company supervision.
• Motivated, organized with excellent Interpersonal skills, analytical skills.
• Strong facilitation and presentation skills preferred.
• Ability to read and communicate in the English Language.
• Performs other duties and assignments as necessary.