Clinical Documentation Integrity (CDI) Specialist

OU Health; Oklahoma City (OK); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare provider is seeking a Clinical Documentation Integrity (CDI) Specialist to enhance the quality of patient care through accurate documentation. This role involves reviewing medical records, collaborating with healthcare teams, and ensuring compliance with documentation standards. The ideal candidate will possess strong communication skills and a background in acute care settings.

Qualifications

• Five years acute care hospital experience required.
• Licensed healthcare experience preferred.

Responsibilities

• Conducts concurrent review of clinical documentation.
• Communicates with physicians regarding documentation.
• Gathers and analyzes information pertinent to documentation.

Skills

Communication

Organization

Adaptability

Education

Associate’s degree

BS in Nursing

Job description

Position Title

Clinical Documentation Integrity (CDI) Specialist

Department

Clinical Document Improvement

Job Description

This position may be performed remotely from the following locations within the United States of America: Arkansas, Colorado, Florida, Georgia, Indiana, Kansas, Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, West Virginia, and Wisconsin.

General Description

The Clinical Documentation Integrity (CDI) Specialist conducts concurrent review of the clinical documentation in the medical record to achieve more accurate and detailed documentation. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. This process aims to improve the quality of patient care, accurately portray the facility's quality outcomes ratings, reduce compliance risks, and ensure appropriate reimbursement.

Essential Responsibilities

1. Provides daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information, and treatment plans.
2. Responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures.
3. Communicates with physicians, face-to-face or via clinical documentation inquiry forms, regarding missing, unclear, or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness.
4. Communicates with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record.
5. Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnoses, impact of procedures on the final DRG, and imparts this knowledge to physicians and other healthcare team members.
6. Gathers and analyzes information pertinent to documentation findings and outcomes.

General Responsibilities

• Performs other duties as assigned.

Minimum Qualifications

Education: Associate’s degree required; BS in Nursing or Registered Nurse preferred.

Experience: Five years acute care hospital experience or RHIA/RHIT/CCS with five years acute care inpatient coding experience required. Licensed healthcare experience (RN, LPN, CRT/RRT) or completion of medical school preferred. Advanced clinical expertise and/or extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting preferred.

License(s)/Certification(s)/Registration(s) Required: CCP, CCDS or CDIP preferred.

Knowledge, Skills, and Abilities

• Excellent verbal and written communication skills.
• Proficiency in organization and planning.
• Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing, and Internet searching.
• Understanding of organizational policies and procedures.
• Working knowledge of quality improvement theory and practice.
• Ability and willingness to seek out and accept change.
• Demonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice.
• Knowledge of federal, state, and private payer regulations.