Clinical Documentation Integrity (CDI) Specialist- Remote
Home Office: Chicago, IL
Job Family:
CDI Specialist
Travel Required:
Clearance Required:
What You Will Do:
The Clinical Documentation Integrity Specialist reviews and analyzes health records to identify opportunities to clarify relevant diagnoses and procedures for distinct patient encounters. Works collaboratively with providers, other health care professionals and coding team to ensure that clinical information in the medical record is present and accurate so that the appropriate utilization, clinical severity, outcomes and quality is captured for the level of service rendered to each patient, as well as ensuring compliant reimbursement of patient care services. This position is full time and 100% remote.
Essential Job Functions:
Strong organizational skills
Proficiency with technology
A Team Player that is able to work independently with minimal supervision
Effective verbal and written communication skills
Ability to interact directly with Physicians and other clinicians in a professional manner
Ability to accommodate flexibility in work schedule based on physician availability
Duties and Responsibilities:
Conducts comprehensive initial and follow-up concurrent reviews of medical records for assigned patients in the time frame, frequency and prioritization as defined for the CDI teamĀ
Identifies opportunities to clarify incomplete or conflicting documentation and/or to validate diagnosis in the medical record.
Understands the guiding principles of clinical validation and writing a compliant query.
Prepares a compliant written query for responsible treating physician, following the most current ACDIS/AHMIA Guidelines to Achieving a Compliant Query Process
Identifies principal diagnosis options, secondary diagnoses and significant procedures in order to assign working MS-DRG.
Establishes a working DRG and updates DRG based on record documentation during concurrent reviews to reflect current expected Length of Stay as appropriate
Utilizes the appropriate UAB query template and follows 2022 ACDIS/AHIMA Guidelines to Achieving a Compliant Query Process
Ensures relevant and/or approved clinical indicators specific to the patient and the clinical record are cited on the query template.
Choices provided on the query must reflect reasonable conclusions specific to the patient and the clinical record
Demonstrates knowledge of Patient Safety Indicatorās (PSIās), Hospital Acquired Conditions (HACās), Severity of Illness & Risk of Mortality (SOI/ROM) as well as present on admission status
Ability to appropriately apply and use hospital approved clinical indicators for specified diagnoses
Ability to follow hospital specific procedures and policies with regards to documentation requirements, query escalation, DRG reconciliation and other duties.
Tracks physician query response documented in the medical record.
Maintains productivity and established performance benchmarks for ā¦
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100% remote None
Benefits/Perks100% Remote Basic Life & Supplemental Life Childcare Program Company paid holidays Corporate Sponsored Events & Community Outreach Dental Emergency Back-Up Childcare Program Employee Referral Program Flexible Spending Accounts Flexible Work Schedule Fully remote Health savings account Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts Medical 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- Collaborate with healthcare professionals
- Communication
- Training
Analytical Anatomy Clinical Documentation Clinical Validation Coding Coding Guidelines Communication Critical thinking HIPAA ICD ICD-10 ICD-10 Coding Medical Records Medical terminology Microbiology Organizational Physiology Productivity Quality Technology Proficiency Training Verbal and written communication Verbal communication Written communication
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