Clinical Documentation Integrity (CDI) Specialist - Remote

Job Family:

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.

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 team 

• 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 Indicator’s (PSI’s), Hospital Acquired Conditions (HAC’s), 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 quality

• Ensures competency in use of CDI application …