CDI Specialist I Inpatient

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Facilitates improvement in the overall quality and completeness of clinical documentation to assure accurate coding assignment, severity of illness and risk of mortality through extensive interaction with, and education of, providers and multidisciplinary team members. May perform at a level requiring continued feedback and monitoring or mentoring

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

 

1. In collaboration with the providers and staff, identifies and records principle diagnoses, secondary diagnoses, procedures, and assigns a working Diagnostic Related Group (DRG).

2. Conducts initial concurrent review and ongoing re-reviews for all selected admissions by documenting findings regarding DRGs, APR-DRGs and Value Based Purchasing/Quality measures.

3. Identifies need to clarify documentation through quality audits in records and initiates communication with physician, nurse, or patient care coordinator by utilizing the appropriate “query” tools in order to capture the documentation in the medical record that accurately supports the patient’s severity of illness.

4. Provides information and ongoing education as necessary to providers and staff on documentation issues, guidelines, and unanswered queries.

5. Promotes compliance with CMS, Medicare documentation, and coding and billing regulations.

6. Participates in the processes to assess and improve the services provided and compliance with regulatory requirements. Reports results assessment and improvement processes to the appropriate administrative levels.

7. Collaborates with the Quality Department to ensure documentation meets quality initiative standards used for measuring and reporting hospital and provider outcomes.

8. Collects, analyzes and submits timely, accurate and complete reports of clinical documentation information used for measuring and reporting Hospital and Provider outcomes data.

9. Facilitates in the education and training of new associates concerning clinical documentation improvement guidelines and processes. This may include providers, CDIs, coders, and other healthcare providers.

10. Works with the Coding Specialists on any issues that arise concerning documentation, providers, and queries to enhance the concurrent process to enable prompt coding.

11. May provide educational support in terms of clinical/coding or process at manager’s discretion and as need arises.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

1. Must be able to sit for long periods of time.

2. Must have visual and hearing acuity within the normal range.

3. Must have manual dexterity needed to operate computer and office equipment.

WORKING