Clinical Documentation Integrity Specialist-Full-Time

MACON HOSPITAL INC; Lafayette (TN); On-site; USD 67,000 - 89,000; Full time

Job summary

MACON HOSPITAL INC seeks a Clinical Documentation Integrity Specialist for a full-time position in Lafayette, TN. The CDI specialist will perform concurrent and retrospective reviews of inpatient records, querying providers to ensure accurate documentation and proper coding to support DRG assignments.

The role requires an active RN license and 3+ years of CDI experience in an inpatient setting, with proficiency in ICD-10-CM/PCS, MS-DRG and APR-DRG payment models, plus strong communication and

Qualifications

• RN license required.
• 3+ years CDI experience in inpatient facility.
• Experience with ICD-10-CM/PCS, MS-DRG and APR-DRG payment models.
• Knowledge of AHIMA Query Guidelines and coding standards.

Responsibilities

• Performs concurrent and retrospective review of inpatient records to improve documentation quality.
• Communicate with providers to ensure accurate documentation of diagnoses and procedures.
• Generate compliant clinical queries for clarification of diagnoses and quality indicators.
• Provide CDI education and support to hospital staff and coding teams.
• Collaborate with providers, case managers, and HIM professionals to ensure coding accuracy and address DRG discrepancies.

Skills

Critical thinking

Communication skills

Time management

Education

Active RN License

Tools

Microsoft Word

Microsoft Excel

PowerPoint

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