Clinical Documentation Improvement Specialist

Crusader Community Health; Rockford (IL); On-site; USD 40,000 - 59,000; Full time

Job summary

Crusader Community Health in Rockford, IL seeks a Clinical Documentation Improvement (CDI) Specialist to educate providers and serve as the SME for documentation, collaborating with coders to improve accuracy of medical records.

This full-time role requires certification in medical coding or RHIA/RHIT, strong knowledge of ICD-10-CM, MS-DRG, APR-DRG, and the ability to audit records and build cross-functional relationships.

Qualifications

• Certification in medical coding or health information management is required.
• Expert knowledge of medical documentation guidelines and coding systems (ICD-10-CM, MS-DRG, APR-DRG, HCCs).
• Ability to audit medical records and advise providers.

Responsibilities

• Educates providers on accurate outpatient documentation.
• Performs audits of medical records to ensure complete documentation and coding.
• Acts as liaison between providers and coders to align understanding of documentation uses.
• Builds collaborative relationships to improve documentation quality.

Skills

Medical documentation knowledge

Auditing

Provider education

Interpersonal collaboration

Education

CPC

CCS

CCS-P

RHIA

RHIT

CDS

CDIP

CDIS

Job description

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Clinical Documentation Improvement Specialist

HIS Full Time Professional Rockford, IL, US

Salary Range: $39,618.50 To $59,428.25 Annually

Clinical Documentation Improvement (CDI) Specialist

POSITION SUMMARY:

Educates providers and serves as the subject matter expert for any topic related to provider documentation in the organization. Is an advisor to providers regarding complete and accurate outpatient documentation and functions as a liaison between providers and coders with the goal of creating mutual understanding of the many uses of medical record documentation. Working independently, the Clinical Documentation Improvement (CDI) Specialist performs audits of the medical record to ensure the capture of complete and accurate provider documentation and coding. The CDI Specialist will develop collaborative relationships and possess excellent interpersonal skills in building and maintaining crucial relationships so that the most complete and accurate provider documentation can be achieved.

EDUCATION REQUIREMENTS:

At least one of the following certifications is required: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Coding Specialist Physician-Based (CCS-P), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Clinical Documentation Specialist (CCDS, Certified Documentation Improvement Practitioner (CDIP), or Clinical Documentation Improvement Specialist (CDIS)

Knowledge Of:

• Expert level of knowledge and ability to apply medical documentation guidelines and practices.
• Knowledge of, but not limited to, current coding guidelines and methodologies, MS-DRG, APR-DRG, HCCs; ICD-10-CM coding guidelines and conventions.
• Extensive knowledge of medical terminology, anatomy and pathophysiology and ancillary test results.

Crusader Community Health serves the Rock River Valley area with quality primary health care for all people in need. CCH provides a comprehensive benefits package which includes: Medical, Dental, Flexible Spending/Health Savings Account, Life Insurance, Accident Coverage, Critical Illness Coverage. Employees enjoy company paid Life Insurance, Short Term Disability and Long-Term Disability, paid Holidays, Personal Days, accrued Paid Time Off hours (PTO)- 18 days in the first year, and continuing medical education time and financial reimbursement. Additionally, employees may enroll in the CCH 403(b) Retirement Plan, with employer match after one year of service.

Crusader Community Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, marital status, age, national origin, ancestry, physical or mental disability, medical condition, pregnancy, genetic information, gender, sexual orientation, gender identity or expression, veteran status, or any other status protected under federal, state, or local law.