CDI RN Specialist - Remote

JOB SUMMARY 

Responsible for reviewing medical records to facilitate and obtain 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, by improving the quality of the physicians’ clinical documentation. Exhibits a sufficient knowledge of clinical documentation requirements, MS-DRG Assignment, and clinical conditions or procedures. Educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management.     

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

• Record Review: Completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness; and (b) initiate a review worksheet.  
• Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary.
• Formulate physician queries regarding missing, unclear or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary.
• Collaborates with case managers, nursing staff and other ancillary staff regarding interaction with physicians regarding documentation and to resolve physician queries prior to discharge. 
• Assist in training department staff new to CDI
• Professional Development: Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-9-CM and CPT coding. Attends mandatory coding seminars on annual basis (IPPS and OPPS, ICD-9-CM and CPT updates) for inpatient and outpatient coding. Quarterly review of AHA Coding Clinic. Attends Quarterly Coding Updates and all coding conference calls as well as any required CDI education.  
• CDI: Communicates/Completes Clinical Documentation Improvement (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolution
• Other duties as assigned

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• CDI Specialist must display teamwork and commitment while performing daily duties
• Must demonstrate initiative and discipline in time management and medical record review
• Travel may …