Clinical Documentation Integrity Specialist

Community hospital part of a system looking to bring on a CDI Specialist!

• Reports to the Corporate Director of Health Information Management
• Responsible for improving the quality, completeness and accuracy of clinical documentation
• Works concurrently with providers and the healthcare team to ensure documentation accurately reflects the patient’s clinical condition and level of service
• Uses compliant provider queries to clarify missing, conflicting, unclear or clinically unsupported diagnoses
• Reviews and supports accurate assignment of MS-DRG, APR-DRG, Severity of Illness (SOI) and Risk of Mortality (ROM)
• Identifies relevant clinical indicators including HACs and PSIs
• Strong emphasis on clinical validation and compliant querying under AHIMA/ACDIS guidelines
• Individual contributor role with no direct reports

Qualifications:

• Bachelor’s degree preferred
• 1+ year of inpatient CDI experience required; ideally 2+ years
• Strong understanding of MS-DRG, APR-DRG and ICD-10-CM/PCS
• Strong clinical background, such as an RN/BSN or foreign-trained physician
• Experience with EHR and encoder systems required
• Must have or obtain CCDS or CDIP certification within 1 year of hire