What are the responsibilities and job description for the Clinical Documentation Integrity Consultant position at Professional Credit Service?
Clinical Documentation Integrity (CDI) Consultant ensures patient records accurately reflect their clinical status for quality care, proper coding, and compliant reimbursement by collaborating with providers, analyzing documentation for gaps, and educating staff on best practices and improving overall documentation quality.
Limited Duration of 6 months or longer and possible permanent employment. Onsite 2 days, remote 3 days.This is a full-time hybrid employment opportunity located in Lake Charles Louisiana.
Responsibilities
- Ensures diagnoses and procedures translate correctly into coded data for billing and reporting.
- Captures full patient severity, complexity, and risk factors for appropriate payment (e.g., DRG/MS-DRG/APR-DRG).
- Paints a complete picture of the patient's condition for quality metrics, research, and regulatory compliance.
- Provides the entire care team with necessary information for high-quality, informed decision-making.
Duties
- Examine medical records (concurrently and retrospectively) for completeness, accuracy, and specificity of diagnoses and procedures.
- Train staff on documentation standards, disease severity, complexity, and regulatory requirements (like DRGs, HCCs).
- Send clarification requests to providers to get more detailed documentation.
- Analyze data to identify trends and opportunities for improvement in documentation.
- Implement CDI program with actionable insights to help drive accurate documentation and coding, improve care quality and reduce missed opportunities while creating efficiencies and productivities that drive impressive financial and quality opportunities.
- Enhance clinical workflows and streamlines processes for CDI reviewers and risk coders.
Qualifications:
- At least 5 years’ experience in CDI and coding built on performance, compliance, clinical content and hands-on consulting resulting in high-impact financial and quality outcomes.
- Must have 3 years minimum experience implementing improvement projects based on prioritized opportunities to enhance financial and quality improvements. Close the loop between front-end clinician workflows and back-end CDI workstreams seamlessly to help improve documentation, simplify query response and accelerate the revenue cycle.
- Must have active Clinical Documentation Integrity Specialist (CDIS) or Certified Documentation Improvement Practitioner (CDIP) certification, and coding credentials (CCS or CPC).
- Knowledge of DRG coding, ICD-10, electronic health records (EHRs), and strong communication/teaching skills.
- Detail oriented, with strong time management and planning skills to effectively meet deadlines
- Strong technological skills with the ability to quickly and efficiently learn new systems, potentially working in more than one system at the same time.