Clinical Documentation Improvement Specialist - CDI Specialist

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Summary:

Evaluates and analyzes medical records concurrently for proper documentation.

Collaborates with HIM Coders, clinicians and medical staff to ensure timely and accurate documentation that supports the diagnosis and treatment of the patient.

Collaborates with Physicians, Medical Directors, Quality Directors, Case Managers, Nurse Directors and Assistant Nurse Managers on cases that are not meeting standards, and assists with the development of action plans to improve outcomes.

Position Responsibilities:

* Evaluates and analyzes medical records concurrently for proper documentation. This review includes new admissions to the facility, as well as re-reviews every two - three days until the patient is discharged.

* Manages and trends data collection for an assigned hospital / facility/ specialty.

Conducts post discharge reviews for comparative analysis of CDI Specialist and HIM APR-DRG severity level assignment and denial management.

* The CDI Specialist is the primary source to verify diagnoses in the medical record for proper DRG coding. When symptoms in the medical record require further documentation, the CDI Specialist queries the physician for a specific diagnosis/procedure for more accurate DRG coding.

* Collaborates with HIM Coders, clinicians and physicians to ensure documentation that supports the diagnosis and treatment of the patient is timely and accurate documentation.

* Provides on-going training and education to the clinicians and physicians during 1:1, physician group, performance improvement and ad hoc meetings.

* Collaborates with HIM Coding, Quality and Case Management Department by reviewing medical records that are not meeting standards, and assists with the development of action plans to improve documentation for peer review of medical and nursing staff's documentation.

* Assists the Director and the hospital team in with preparation, coordination and response to areas of documentation improvement.

* When fall outs of accepted criteria occur, the CDI Specialists reviews the information with the physicians, clinicians, HIM and Quality Department.

* Assists with the development and implementation of performance improvement activities according to the Virtua Quality Plan.

* Uses the DMAIC cycle and assists in educating and coaching staff, managers and physicians in its use.

Position Qualifications Required:

Required Experience:

Two years hospital clinical experience required.

Required Education:

Bachelor's degree preferred.

Training / Certification / Licensure:

Current NJ RN Licensure required or previous MD experience required. Coding skills with experience in ICD-9-CM and working knowledge of the AHA Coding Clinic preferred.

Must demonstrate the ability to accurately use a computer and standard office software such as Microsoft Excel, Word, Access and Power Point. Analytical skills. Must demonstrate effective verbal and written communication skills. Must be able to establish and maintain an effective rapport with staff, physicians, managers and administrators. Ability to coordinate multiple tasks and flexibility to balance changing priorities.