Clinical Documentation Integrity Specialist-Full-Time

Macon Community Hospital; Lafayette (TN); On-site; USD 44,000 - 59,000; Full time

Job summary

Macon Community Hospital in Lafayette, TN is seeking a Clinical Documentation Integrity Specialist to oversee inpatient documentation and promote accurate coding aligned with AHIMA guidelines. You will perform concurrent and retrospective reviews, engage with providers to clarify diagnoses and procedures, and support the Coding Team and Health Information Management professionals.

Requires an active RN license and 3+ years CDI experience in an inpatient setting, with ICD-10-CM/PCS, DRG

Qualifications

• Active RN license required.
• 3+ years working experience as CDI Specialist for Inpatient Facility.
• Proficiency in ICD-10-CM/PCS and DRG payment models.
• Excellent clinical communication and ability to work with Providers and Health Information Management Professionals.

Responsibilities

• Performs concurrent and retrospective review of inpatient records for documentation quality.
• Communicate with providers to clarify diagnoses, procedures, and quality indicators.
• Generates compliant clinical queries for clarifying Principal Diagnoses, Secondary Diagnoses, Procedures, SOI, ROM and Quality Indicators.
• Collaborates with Providers, Case Managers, Coding Team and Health Information Management Professionals to ensure coding accuracy and address DRG discrepancies.
• Reports to Hospital Leadership and designated Facility Director; supports Utilization Review and discharge planning.

Education

Active RN License

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Clinical Documentation Integrity Specialist-Full-Time

Full Time Clerical Lafayette, TN, US

2 days ago Requisition ID: 1145

Salary Range: $32.00 To $43.00 Hourly

CLINICAL DOCUMENTATION INTEGRITY SPECIALIST

Qualifications

• Active RN License

JOB REQUIREMENTS

• The (Hospital) Clinical Documentation Integrity (CDI) Specialist will perform concurrent and retrospective reviews of inpatient records for documentation compliance. Communicate effectively with Providers regarding missing, unclear, or conflicting health record documentation and identify opportunities to clarify Principal Diagnoses, Secondary Diagnoses, Procedures and Quality Indicators. Promote accurate capture of clinical severity to support level of service rendered to patients.
• Demonstrate an understanding of complications, comorbidities, severity of illness (SOI), risk of mortality (ROM) case mix, and the impact of procedures on the billed record, as well as the ability to impart this knowledge to providers and other members of the healthcare team.

DUTIES AND RESPONSIBILITIES

• Performs concurrent and retrospective review of inpatient records and identifies opportunities to improve quality of documentation.
• Communicate with providers to promote accurate and complete documentation of diagnoses and/or procedures in the health record.
• Generates compliant, clinical queries for clarifying Principal Diagnoses, Secondary Diagnoses, Procedures, Severity of Illness (SOI), Risk of Mortality (ROM) and Quality Indicators
• Provides clinical support for Coding Team and performs clinical validation
• Collaborate with Providers, Case Managers, Coding Team and Health Information Management Professionals to ensure coding accuracy, and address DRG discrepancies
• Reports to Hospital Leadership and designated Facility Director
• Provides CDI education to Hospital Leadership, Physicians, Clinicians, Coders and Health Information Management Professionals to improve documentation quality and to optimize quality of patient care
• Creates reports summarizing identified trends, variances, analyses, and CDI impact
• Participates in meetings with Hospital Leadership, Department Chairs, Division Chiefs, Physicians, Clinical Teams, Coding Teams and Health Information Management Professionals to provide feedback and suggestions for improvement of documentation quality

MINIMUM REQUIREMENTS

• CDIP, CCDS or CCS credential preferred
• 3+ years working experience as CDI Specialist for Inpatient Facility
• 3+ years working experience with ICD-10-CM/PCS code sets and MS-DRG and APR-DRG payment models
• Expertise in CDI workflow and adherence to AHIMA Query Guidelines
• Adherence to ICD-10-CM/PCS Official Guidelines for Coding and Reporting, AHA Coding Clinic, ACDIS ethical guidelines, AHIMA Standards of Ethical Coding, CMS and other regulatory guidelines
• Proficiency in Microsoft Word, Excel and PowerPoint
• Excellent critical thinking skills
• Knowledge of Utilization Review preferred
• Excellent oral and written communication skills
• Ability to complete projects and meet deadlines with time constraints
• Assists with Utilization Review and Discharge Planning