What are the responsibilities and job description for the Clinical Documentation Integrity (CDI) Specialist position at Health Information Associates (HIA)?
As a Clinical Documentation Integrity (CDI) Specialist, you will collaborate with physicians, nursing staff, other patient caregivers, and medical records coding staff to enhance the quality, specificity, accuracy, and completeness of documentation of care provided and coded. Your responsibilities will include reviewing medical records for opportunities for diagnosis clarification and validity, ensuring accurate DRG assignment, severity of illness, risk of mortality, and case mix data, and monitoring clinical indicators such as HACs, PSI, mortality, etc. You will adhere to all coding and clinical documentation improvement guidelines endorsed by ACDIS and AHIMA, following AHIMA guidelines and Health Information Associates policies and procedures.
* This is a remote/work from home position.
Experience Required:
- Recognized CDI credential from ACDIS (CCDS)
- Current active RN license
- Current AHIMA or AAPC coding credential, preferred
- Three or more years of experience working as a clinical documentation specialist
- Three years or more of clinical experience in an acute care setting
Responsibilities:
- Adhere to all coding and clinical documentation improvement guidelines endorsed by ACDIS and AHIMA.
- Analyze records for potential query opportunities, appropriate DRG assignment, severity of illness, risk of mortality, and case mix data, as well as clinical indicators (HACs, PSI, mortality, etc.)
- Research, analyze, and respond to inquiries regarding queries issued and their compliance, potential coding errors, diagnoses at risk for denials, and reconciliation of CDI reviewed charts.
- Conduct clinical documentation reviews and audits as assigned meeting productivity standards set by record type for each project or client.
Salary : $42 - $48