CDI Specialist: Elevate Medical Record Quality

University of Southern California; Arcadia (CA); On-site; USD 64,000 - 84,000; Full time

Job summary

University of Southern California Arcadia Hospital seeks a CDI Specialist to review medical records and improve the accuracy and completeness of clinical documentation. The role involves collaboration with physicians, HIM professionals and nursing staff, with emphasis on ICD-10/ CPT guidelines and HIPAA compliance.

Candidates should have strong coding knowledge and the ability to initiate documentation queries.

Qualifications

• Minimum three years’ experience in clinical disciplines or utilization review in an acute care facility.
• Strong knowledge of ICD-10-CM/ICD-10-PCS coding conventions and guidelines.
• Initiate clinical documentation queries to obtain complete documentation.

Responsibilities

• Review medical records to improve the specificity of physicians' clinical documentation.
• Collaborate with physicians, HIM staff, and nursing to improve documentation and coding.
• Maintain confidentiality and HIPAA compliance; inform HIM leadership of workflow status.

Skills

ICD-10 knowledge

Coding guidelines

Query initiation

Communication skills

HIPAA compliance

Education

Nursing BSN or RHIT/RHIA

Anatomy/Physiology coursework

Tools

Windows

Coding software

Job description

University of Southern California Arcadia Hospital seeks a CDI Specialist to review medical records and improve the accuracy and completeness of clinical documentation. The role involves collaboration with physicians, HIM professionals and nursing staff, with emphasis on ICD-10/ CPT guidelines and HIPAA compliance.

Candidates should have strong coding knowledge and the ability to initiate documentation queries.