Clinical Document Improvement Specialist- 40/hrs, Day Shifts

Temple Health – Temple University Health System; Huntingdon Valley (PA); On-site; USD 65,000 - 92,000; Full time

Job summary

Temple Health – Temple University Health System is seeking a CDI Specialist to support documentation and accurate coding for inpatient records in Huntingdon Valley, PA. The role focuses on improving documentation quality and educating care teams on ICD-10 impact and DRG classification.

The CDI Specialist will review records daily, abstract relevant clinical data, and translate findings into ICD-10 compliant coding.

Qualifications

• Bachelor's degree in a related field or an Associate's degree in a healthcare related field.
• 2 years experience in Patient care or Coding (inpatient medical setting) Required
• 5 Years Experience In Inpatient Acute Care Preferred

Responsibilities

• Serve as primary resource to the treatment team on medical record documentation to support accurate classification of severity of illness/complexity.
• Educate staff on the ICD-10 classification system and implementation.
• Review daily inpatient records, abstract clinical information and translate into hospital coding system (ICD-10).
• Identify opportunities to improve documentation to support accurate DRGs, SOI, ROM, and quality reporting.
• Communicate with clinical staff to educate and obtain clarification of documentation.

Education

Bachelor's Degree or Associate's degree in healthcare field

2 years experience in Patient care or Coding (inpatient medical setting)

5 years inpatient acute care preferred

Job description

Category

Operational Admin & Management Support

Job Location

445 Shady Lane, Huntingdon Valley, Pennsylvania, United States

Tracking Code

264828

Weekly Hours

40.00

Schedule

Full-Time

Shift

Day Shift
Serves as the primary resource to the treatment team on all aspects of medical record documentation required to support the accurate classification of patient's severity of illness/medical complexity. Possess extensive knowledge of both clinical medicine and disease management, as well as the internal and external patient classification systems that measure patient's severity of illness and medical complexity. Additionally, the CDI specialist will be the primary educator for the implementation of the International Classification of Disease Classification System, 10th revision. The CDI specialist shall be responsible for clarifying documentation regarding quality of care issues. Responsible for the daily review of current inpatient medical records, abstracts pertinent clinical information and translates the clinical information into a hospital based coding system utilizing ICD-10. Identifies opportunities for documentation improvement to support accurate assignment of diagnostic related groups (DRGs), severity of illness (SOI) assignment, risk of mortality (ROM) assignment, and correct reporting of quality metrics. Communicates with the clinical staff through a variety of means to educate the staff and obtain clarification of documentation.

Education

Bachelor's Degree in a related field or an Associate's degree in a healthcare related field

With 5 Years Of Related Experience Required Or

Combination of relevant education and experience may be considered in lieu of degree Required

Experience

2 years experience in Patient care or Coding (inpatient medical setting) Required

5 Years Experience In Inpatient Acute Care Preferred

Licenses

• Certified Coding Specialist Preferred Or
• PA Practical Nurse License Preferred or
• PA Registered Nurse License Preferred
• Multi State Compact RN License Preferred Or