HIS – CDI Specialist 40 hrs/wk, 1st shift
PURPOSE OF THIS POSITION The primary purpose of the Clinical Document Integrity (CDI) Specialist position is to improve the quality...
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Findlay, OhioHancock County
PURPOSE OF THIS POSITION
The primary purpose of the Clinical Document Integrity (CDI) Specialist position is to improve the quality of provider documentation in order to effectively translate into accurate coded data which is representative of the patient’s episode of care/intensity of service. The objective is to ensure the integrity and quality of the data reported is supported by provider clinical documentation to accurately reflect reimbursement and quality reporting which influences provider and hospital profiling. The CDI Specialist reports to the Coding Compliance Supervisor.
During the performance process, please assess the level at which the staff member achieves the job accountabilities. Please use the “Comments” section to document specific examples of performance issues, staff member’s strengths and/or shortcomings, areas of suggested performance improvement and other comments as appropriate to further the staff member’s growth and development.
Duty 1: Analyze clinical documentation in an inpatient and/or outpatient setting to identity documentation improvement opportunities which may have an impact on coding, quality reporting and/or reimbursement outcomes. Develop action plans and provide recommendations to improve identified opportunities or risks.
Duty 2: Provide or coordinate education to healthcare providers regarding the importance of accurate and complete documentation in the health record and impact on quality of data and impact on reimbursement and quality metrics. This includes attendance and presentation to necessary medical staff committees, individual education, and written communication (e.g. letters, newsletters, etc.).
Duty 3: Perform concurrent review of inpatient medical record in coordination with concurrent coder to identify documentation improvement opportunities related to coding and quality initiatives. Interact with providers through written queries and/or verbal communication as appropriate. Support HIS Coding team on retrospective query process and interact with provider to facilitate resolution, as needed.
Duty 4: Partners with the HIS coding team to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine working and final DRG, severity of illness and/or risk of mortality.
Duty 5: Participates in third party payer audits and assists in defending clinically focused take-backs and in the appeal process. Supports resolution of identified issues; documents relevant decisions related to coding practice and charging in policies or procedures to promote ongoing standardization and consistency.
Duty 6: Partner with other key areas to insure an accurate and compliant picture of clinical care per the clinical documentation to support compliant coding and accurate reimbursement.
Duty 7: Analyzes and trends statistical data of internal practices and industry resources (e.g. PEPPER report, Integrity Audit issues, RAC, OIG, Healthgrades, etc.) to identify documentation improvement opportunities and makes recommendations to address issues.
Duty 8: Collect track and monitor and reports identified CDI metrics. Analyzes data and makes recommendations to address areas of opportunity or risk. Assists in the preparation and presentation of clinical documentation monitoring/trending reports for leadership, medical staff and other key audience relevant to the findings.
Duty 9: Support organizational initiatives impacted or dependent on the quality of clinical documentation; this may include performing chart reviews, educating departments or teams, participating in Performance Improvement events, provide support to other areas
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