CDI Specialist (USRN Compact License) | Open budget

Minimum Requirements

• Bachelor's degree in nursing
• Three to five (3-5) years of recent clinical work experience in the medical-surgical area, ICU, telemetry, or emergency department
• Active USRN license
• Solid background in fundamentals of nursing and medical & surgical nursing
• Knowledge about diagnoses, signs & symptoms, diagnostic tests and management expected for conditions such as DM, HTN, CHF, CVA, sepsis, encephalopathy, AKI, CKD, etc.

Job Description :

Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patients' rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.

Employees must perform all duties and responsibilities in accordance with hospital programs. Clients with EPIC EMRs may require onsite work at designated office locations.

Reviews clinical documentation to facilitate the accurate representation of the severity of illness, expected risk of mortality, and complexity of care by improving the quality of the physician's clinical documentation.

Communicates review results to department leadership, CDI Specialists, and other appropriate staff. Makes recommendations for corrective action.

Conducts focused reviews in areas identified by CDI leadership : Mortality reviews, PSI reviews, as well as other identified projects.

Develops and presents ongoing education to CDI specialists and related departments on current documentation trends, CDI practices, focus areas, and areas of opportunity identified through the analysis of clinical and documentation data from a variety of internal and external sources. Leads new CDI specialist orientation.

Serves as a subject matter expert and authoritative resource on interpretation and application of CDI practices, coding rules and regulations, and conducts risk assessments of potential and detected compliance deficiencies, as well as documentation improvement opportunities.

Utilizes hospital coding code sets, policies and procedures, Federal and State coding reimbursement guidelines, and the application of Coding Clinic Guidelines to assign working DRGs, reviewing patient records throughout hospitalization that have been identified as focus DRGs by regulatory agencies or the facility to ensure the codes are reported at the highest specificity.

Initiates physician interaction when ambiguous, missing, or conflicting information is present in the medical record through the physician query process and / or participation in rounding with physicians by requesting additional documentation necessary for correct coding and compliance, accurately reflecting CMI, LOS, and optimal resource utilization.

Partners with the HIMS coding staff to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, risk of mortality, and quality outcomes.

Leads provider engagement and the establishment and maintenance of relationships related to CDI and documentation improvement efforts.

Leads and manages ongoing documentation improvement initiatives, including formal and informal education plans related to clinical documentation improvement.

Leads and / or participates in department and organizational projects related to documentation improvement.