CDI Specialist: Elevate Clinical Documentation

University Medical Center, Inc.; United States; Remote; USD 75,000 - 95,000; Full time

Job summary

UofL Health is seeking a Clinical Documentation Improvement Specialist (CDIS) to review inpatient medical records, assign MS-DRGs, and improve documentation accuracy. The role involves collaborating with physicians and the care team to clarify health record details and ensure compliant coding.

CDI certification or related credentials are expected within 12 months of employment. Ideal candidates will have RN licensure or coding credentials, with knowledge of Official Coding Guidelines, healthcare

Qualifications

• Ability to rapidly review inpatient records and determine documentation opportunities.
• Knowledge of Official Coding Guidelines and POA concepts.
• Experience with MS-DRG assignment and case-mix analysis is preferred.

Responsibilities

• Review inpatient records within 24-48 hours of admission for MS-DRG accuracy.
• Collaborate with physicians to obtain missing documentation and clarify health record details.
• Prepare physician queries to support accurate coding and documentation.
• Stay current with CDI training and participate in ongoing education.

Skills

Medical terminology

Coding Guidelines

Independent worker

Communication skills

Analytical thinking

Problem solving

Detail oriented

Organization skills

Multitasking

Computer literacy

Database analysis

Spreadsheet analysis

Presentation software

Word processing

Internet research

Regulations knowledge

Quality improvement

Core measures

Safety

Reporting programs

Physician queries

Education

RN licensure

Coding credential (CCS/CPC-H)

RHIA/RHIT

CDIS/CDIP certification within 12 months

Tools

Workday

Job description

UofL Health is seeking a Clinical Documentation Improvement Specialist (CDIS) to review inpatient medical records, assign MS-DRGs, and improve documentation accuracy. The role involves collaborating with physicians and the care team to clarify health record details and ensure compliant coding.

CDI certification or related credentials are expected within 12 months of employment. Ideal candidates will have RN licensure or coding credentials, with knowledge of Official Coding Guidelines, healthcare