CDI Specialist

AHMC HealthCare; Riverside (CA); On-site; USD 85,000 - 120,000; Full time

Job summary

AHMC HealthCare seeks a Clinical Documentation Improvement (CDI) Specialist to review inpatient records and educate clinicians to ensure documentation accurately reflects patient acuity and hospital reimbursement rules.

The candidate must hold CCS or AHIMA CDI/CDIP certifications, have at least 2 years of CDI-S experience in acute care (on-site), and demonstrate strong communication, critical thinking, and collaboration with physicians, nurses, and coding staff.

Qualifications

• Excellent written and verbal communication skills.
• Strong clinical knowledge and commitment to clinical relevancy.

Responsibilities

• Review inpatient records (concurrent/retrospective) and educate care providers to improve documentation.
• Ensure documentation supports MS-DRG assignment, case mix index, severity of illness, risk of mortality, and reimbursement rules.
• Interact with physicians, nurses, and coding staff to reflect patient acuity for quality reporting and reimbursement.
• Work in a fast-paced environment with high physician and coding staff interaction.

Skills

Communication skills

Critical thinking

Interpersonal skills

Listening skills

Independent work

Clinical knowledge

Education

CCS AHIMA

AHIMA CDI/CDIP

Job description

Clinical Documentation Improvement (CDI) Specialist will provide active concurrent/retrospective review of inpatient medical records, provide feedback and educate clinical care providers to improve the documentation of all conditions, treatments and care plans within the health record to accurately reflect the condition of the patient and promote patient care. In addition, documentation should reflect documentation associated with MS-DRG assignment, case mix index, severity of illness, risk of mortality, physician profiling, and hospital profiling and reimbursement rules.

In this role, you will facilitate improvement in medical record documentation by interacting with and educating physicians, nurses and coding staff to ensure medical records accurately reflect patient acuity for quality reporting and reimbursement. The ideal candidate will thrive in a fast-paced environment, with high physician and coding staff interaction.

CCS AHIMA certification required. ACDIS CDI certification or AHIMA CDIP certification required. At least 2 years experience as CDI-S in acute clinical environment (not remote) required. Strong clinical knowledge and demonstrated commitment to maintaining relevancy in clinical field. Familiarity with ICD-10-CM Official Coding Guidelines. Excellent written and verbal communication skills, critical thinking skills, listening skills and interpersonal skills to build effective partnering relationships with physicians, care management team, nursing staff, coding staff and other hospital staff Ability to work independently in a time oriented environment. Ability to analyze problems and issues from a variety of perspectives and understand the legal, reimbursement and impact.