CDI Coordinator FT On-Site

Clinical Documentation Integrity Specialist

The purpose of this role is to improve overall quality and completeness of medical clinical documentation to substantiate medical necessity of services and facilitate accurate coding through extensive interaction with physicians, case managers, nursing staff, quality professionals, HIM professionals, and other patient caregivers.

Education & Qualifications:

Graduate of an accredited School of Nursing, BSN preferred

Required Licenses/Certifications:

• Licensed as a Registered Nurse in the state of Texas preferred.
• Certification in Clinical Documentation Integrity from ACDIS, AHIMA, or AAPC

Work Experience:

• Three to five years of inpatient and outpatient hospital CDI experience
• Utilization Review experience including applying Interqual and Milliman Care Guidelines (MCG) along with payer specific medical guidelines and how to apply them to an appeal
• Experience reviewing and analyzing denied/downgraded MS-DRG and APR-DRG accounts received from payers (i.e.: Medicare, Commercial, and Third Party)
• Working knowledge of billing codes, revenue codes, CPT's, ICD-10 CM/PCS
• Experience and knowledge of managed care contracts, account receivables and revenue cycle functions
• Working knowledge of provider billing guidelines, payer reimbursement policies, and related industry-based standards.

Physical Demands & Working Conditions:

The physical demands described here are representative of those that must be met by an employee to successfully to perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The employee is regularly required to lift up to 50 pounds and push or pull heavy objects using up to 50 pounds of force. The employee is frequently required to sit for extended periods of time. Ability to stand and/or walk for extended periods of time. Ability to use fine motor skills to operate office equipment and/or machinery. Ability to utilize full range of body motion in occasionally handling and lifting patients. Ability to receive and comprehend instructions verbally and/or in writing. Ability to use logical reasoning for simple and complex problem solving. Requires normal visual acuity and hearing. Potential for exposure to bodily fluids.

Special Requirements:

Verbal and writing ability required to communicate effectively in informing employees of activities and policies. Numerical ability required. Ability to receive, comprehend, and carry out instructions; ability to work safely with equipment, supplies, and materials; ability to comply with attendance requirements; ability to comply with Human Resource policies. Preferred knowledge of the following: Electronic Medical Record or relational database manipulation language; reporting software.

Essential Duties and Responsibilities:

• Collaborate with case management, coding, and quality teams to ensure continuity of care and accurate data reporting.
• Educate medical staff on the importance of compliant, thorough documentation.
• Issue compliant, timely queries to physicians and healthcare providers to clarify diagnoses, procedures, and treatments.
• Work alongside Case Management to evaluate admission, concurrent, and retrospective patient charts to determine medical necessity and appropriate level of care.
• Ensure documentation accurately captures the Severity of Illness (SOI) and Risk of Mortality (ROM).
• Write clear and concise letters, handle necessary technical vocabulary, and organize difficult or complex information in an understandable and efficient manner
• Serves as a liaison with third party payer and agencies regarding appeals to ensure optimal reimbursement and any other billing or payment issues and ensuring issues are resolved
• Develops recommendations to maintain efficient and effective processes
• Identifies coding and clinical documentation issues and provide recommendations
• Updates patient account record to identify actions taken on account
• Responsible for favorable resolution of third-party payment details, adverse determinations, medical necessity denials, payment discrepancies, and contract misinterpretations
• Review whether DRG's are assigned correctly and if all diagnosis and procedures are identified and documented
• Identify trends and/or opportunities to improve clinical documentation.
• Provides education to the providers regarding clinical documentation improvement and the need for accurate and complete documentation in the patient record
• Works with HIM, Finance and physician groups to develop systems to facilitate complete documentation for data reporting
• Serves as a resource to physicians, case managers, and other key professional staff in matters relating to published DRG information
• Consistently meets established productivity targets for medical record review
• Perform other duties as assigned