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CDI Specialist

Company: Memorial Health
Location: Decatur
Posted on: November 17, 2021

Job Description:

Utilizes clinical and nursing knowledge of documentation requirements to improve overall quality and completeness of clinical documentation of patient records. Works collaboratively with physicians to ensure clinical information in medical record is present and accurate to guarantee the appropriate clinical severity is captured for the level of services rendered.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

  • Knowledge of Clinical Documentation Systems.
  • Working knowledge of DRG and/or APC assignment.
  • Extensive knowledge of pathophysiology, clinical indicators, and medical/surgical nursing.
  • Excellent analysis, communication, and decision-making skills.
  • Ability to work as team member. Responsibilities
    • Facilitates appropriate clinical documentation to support the appropriate diagnosis and procedure coding and to ensure the level of service rendered to all patients is recorded.
      • Follows documentation improvement processes for conducing medical record reviews and meets goals related to appropriate documentation.
      • Assigns a working DRG using coding rules and guidelines.
      • Works with physicians on assigned patient care units to clarify documentation in the medical record.
      • Queries physicians on a concurrent and retroactive basis to ensure documentation appears on the medical prior to billing.
        • Reviews clinical issues with the Health Information Management (HIM) coding staff to assign a working DRG.
          • Identifies missed opportunities related to clinical documentation and coding guidelines and works to ensure accuracy for future coding.
            • Works with Coders, Coding Team Leads and/or Coding Supervisor to resolve differences between CDI and Coding Staff.
            • Coordinates documentation improvement processes with physicians and HIM coding staff to identify those diagnoses that impact severity of illness indicators for each patient.
              • Collaborates with the multidisciplinary team to reflect quality patient outcomes.
              • Identifies clinical indicators that suggest a need for clarification.
                • Adheres to hospital standards to promote a cooperative work environment by utilizing communication skills, interpersonal relationships, and team building.
                  • Contributes to the overall quality of services.
                  • Assumes responsibility for keeping informed about changes in policies and procedures.
                  • Communicates information effectively.
                    • Demonstrates responsibility for personal development by participating in continuing education offerings.
                      • Maintains competence related to DRG assignment, documentation requirements and coding guidelines.
                        • Perform other job-related duties as required . Associated topics: care physician, family, family medicine physician, physician, physician md, physician md do, practice physician, practitioner, primary, urgent

Keywords: Memorial Health, Decatur , CDI Specialist, Other , Decatur, Illinois

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