Clinical Documentation Improvement Specialist

CDI SpecialistPosition is fully remote.Job Description:The CDI Specialist uses clinical and coding knowledge of documentation requirements to improve the overall quality and completeness of clinical documentation as well as relevant diagnoses, procedures and ancillary treatment using a multidisciplinary team process. A complete and accurate medical record will support the appropriate clinical severity to capture the level of service rendered to the patient. The CDI Specialist will collaborate with physicians to improve documentation compliance with criteria requirements under the Inpatient Prospective Payment System, in order to ensure the integrity of the medical record is maintained. The CDI Specialist must be devoted to ongoing, continuous learning of clinical medicine; practical understanding of the International Classification of Disease coding systems and have the ability to educate physicians. Findings and data in the CDI review process shall be shared with the medical staff and multidisciplinary teams for education and solutions in operational excellence of clinical documentation improvement efforts.Responsibilities:Conducts initial reviews and concurrent follow-up reviews of the medical record to ensure the accuracy of the documentation in the medical record.Ensures accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes including evidence-based measures.Queries providers as needed to clarify documentation for specificity and acuity of diagnosis or procedures and treatments, to clarify conflicting documentation and clinical validation meeting UHDDS Guidelines.Ensure the record adequately reflects the severity of illness and risk of mortality equating to intensity of services.Promotes continuity and specificity of clinical documentation in the record.Works with the coding staff in the performance of clinical validation reviews.Provides Clinical Documentation Improvement information to external customers as necessary (i.e., RHIT students regarding Clinical Documentation Specialist Work Queues.Maintains effective and appropriate communication with physicians and other clinicians throughout the organization.Educates physicians and clinicians to ensure capture of appropriate documentation.Participate in ongoing education related to ICD-10, coding guidelines and any other necessary education related to role.Demonstrates knowledge of DRG payor issues, documentation opportunities, clinical documentation requirements and related policy and procedures.Required Skills & Qualifications:Current RN license in the State of Indiana. Bachelor of Science Degree in Nursing preferred.Five (5) years of acute inpatient clinical experience. Critical Care and/or Case Management experience required. Previous CDI experience preferred.Working knowledge of reimbursement systems and coding structures preferred.Excellent verbal and written communication skills.Strong broad-based clinical knowledge and understanding of pathology/pathophysiology.Ability to work independently in a time-oriented environment.Your Extraordinary Career Starts HereWe invite you to join our team of professionals where your unique talents will be well utilized in a work environment that promotes your further growth and development. In return for your valuable service and contributions, Powers Health offers a competitive wage and benefits package along with the necessary tools, resources, and mentoring opportunities to support your career advancement goals.Our comprehensive benefits program includes, but is not limited to:Medical, dental and vision coverageWellness program, including free screeningsHealthcare and Dependent Care Spending Accounts (HSA)Retirement savings planLife insuranceDisability income protectionEmployee Assistance Program (EAP)Fitness center discount programTuition assistance and career developmentPaid Time Off (PTO)Reward and recognition programsJoin our team of healthcare professionals at Powers Health. Apply today!