Clinical Documentation Improvement (CDI) Specialist- Remote
Home Office: Oklahoma City, OK
Job Family:
CDI Specialist
Travel Required:
Clearance Required:
What You Will Do:
The CDI Specialist is responsible for comprehensive secondary clinical chart reviews to identify potential missed opportunities for documentation clarification. Collaborates closely with Coders, Coding Educators, Coding Quality Auditors, Case managers, Quality Department and Providers to assure documentation is clinically appropriate, accurately reflects the severity of illness and risk of mortality for the patient and is reflective of current CMS or other regulatory standards.
- Conducts daily, concurrent review of inpatient records on assigned unit(s) to ensure complete and accurate physician and or clinician documentation is present at the time of discharge for accurate, timely, and compliant coding.
- Reviews daily admissions to assigned unit, perform initial code assignment for a working DRG and complete CDI software data entry for initial and follows up case reviews (or worksheet to include code and DRG assignment) and submit to Program Assistant
- Updates āworking DRGā as documentation supports, or physician query answer supports a change in the DRG assignment.
- Communicates to the CDI Coordinator when volume of daily review assignments is too high or low so that CDI Coordinator can assist in adjusting review assignments amongst the team.
- Initiates compliant physician queries when documentation is confusing, ambiguous, or missing and follows up with MD to seek immediate response to query (utilizing the following AHIMA practice briefs as a guide: āManaging an Effective Query Process,ā October 2008 and āGuidance for Clinical Documentation Improvement Programsā, May 2010).
What You Will Need:
- At least one of the following: RN, MD, or MD Equivalent (MBBS)
- At least 2-4 years acute care inpatient hospital coding or CDI experience
- Familiarity with encoder and DRG assignment
- Maintain current working knowledge of official coding guidelines and coding clinics.
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What Would Be Nice to Have:
- CCDS, CDIP preferred.
- Strong clinical understanding of disease process.
- Demonstrate critical thinking, analytical skills, and ability to resolve problems.
- Strong knowledge of medical terminology, anatomy, physiology, microbiology, and disease processes
- Excellent communication skills, employing tact and effectiveness.
- Ability to converse with physicians in sometimes difficult scenarios.
- Strong typing and computer skills; proficiency with EHR systems, CDI software systems and encoders
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Benefits/Perks401(k) Basic Life & Supplemental Life Childcare Program Company paid holidays Corporate Sponsored Events & Community Outreach Dental Dental Insurance Emergency Back-Up Childcare Program Employee Referral Program Flexible benefits Flexible benefits package Flexible Spending Accounts Health savings account Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts Medical Medical Insurance Medical, Rx, Dental & Vision Insurance Paid holidays Parental leave Personal and Family Sick Time Personal and Family Sick Time & Company Paid Holidays Rx Sick time Skills development Skills Development & Certifications Tuition reimbursement Tuition Reimbursement, Personal Development & Learning Opportunities Variable Incentive Bonus Vision Vision Insurance
Tasks- Communication
- Conduct chart reviews
- Training
Analytical Anatomy Clinical Documentation Coding Coding Guidelines Communication Computer Critical thinking Data Entry EHR systems Encoder Medical terminology Microbiology Organizational Physiology Quality Training Typing
Experience2-4 years
Education Certifications TimezonesAmerica/Anchorage America/Chicago America/Denver America/Los_Angeles America/New_York Pacific/Honolulu UTC-10 UTC-5 UTC-6 UTC-7 UTC-8 UTC-9