Clinical Document Improvement Specialist 40hrs Day Shifts

Temple Health; Huntingdon Valley (PA); On-site; USD 70,000 - 100,000; Full time

Job summary

Temple Health is seeking a CDI specialist to serve as the primary resource for accurate documentation and classification of illness severity and medical complexity. You will educate staff on ICD-10 implementation and ensure high-quality coding for inpatient records.

The role focuses on reviewing records, abstracting clinical data, and translating it into ICD-10 codes, while identifying opportunities to improve documentation and reporting of DRGs, ROM, and quality metrics.

Qualifications

• Bachelor's or Associate degree in healthcare field; 5 years related experience required.
• Combination of relevant education and experience may be considered in lieu of degree.
• Inpatient coding or clinical documentation knowledge preferred.

Responsibilities

• Serve as primary educator for implementing ICD-10 classification system.
• Review daily inpatient records, abstract pertinent clinical information and translate into ICD-10 coding.
• Identify opportunities for documentation improvement to support accurate DRG, SOI and ROM reporting; educate clinical staff as needed.

Education

Bachelor's Degree in a related field

Associate's degree in a healthcare related field

Job description

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