CDI Specialist

Air Combat Effectiveness Consulting Group, LLC; Riverside (CA); On-site; USD 65,000 - 90,000; Full time

Job summary

Air Combat Effectiveness Consulting Group, LLC is seeking a Clinical Documentation Improvement (CDI) Specialist to perform active concurrent/retrospective reviews of inpatient records. You will educate physicians, nurses, and coding staff to ensure documentation accurately reflects patient conditions, treatments, and care plans, aligning with MS-DRG rules and hospital profiling.

The ideal candidate holds CCS/CDIP certifications and has at least 2 years of CDI experience in an acute clinical

Qualifications

• CCS AHIMA certification required.
• ACDIS CDI or AHIMA CDIP certification required.
• 2+ years CDI-S experience in acute clinical environment (not remote).
• Familiarity with ICD-10-CM Official Coding Guidelines.
• Excellent written and verbal communication skills; critical thinking and interpersonal skills.

Responsibilities

• Facilitate improvement in medical record documentation by educating physicians, nurses, and coding staff to reflect patient acuity for quality reporting and reimbursement.
• Collaborate with care teams to ensure documentation supports MS-DRG assignment, severity of illness, risk of mortality, and hospital profiling.
• Engage in ongoing education to maintain relevancy in clinical documentation practices.

Skills

Clinical Documentation

Healthcare coding

Communication skills

Analytical thinking

Team collaboration

Education

AHIMA CCS/CDIP certifications

Job description

Overview

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.

Responsibilities

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.

Qualifications

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.