JOB SUMMARY
Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians’ clinical documentation. Exhibits a sufficient knowledge of clinical documentation requirements, MS-DRG Assignment, and clinical conditions or procedures, educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
- Record Review: Completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness; and (b) initiate a review worksheet.
- Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary.
- Formulate physician queries regarding missing, unclear or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary.
- Collaborates with case managers, nursing staff and other ancillary staff regarding interaction with physicians regarding documentation and to resolve physician queries prior to discharge.
- Assist in training department staff new to CDI.
- Professional Development: Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-9-CM and CPT coding. Attends mandatory coding seminars on an annual basis (IPPS and OPPS, ICD-9-CM and CPT updates) for inpatient and outpatient coding. Quarterly review of AHA Coding Clinic. Attends Quarterly Coding Updates and all coding conference calls as well as any required CDI education.
- CDI: Communicates/Completes Clinical Documentation Improvement (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolution.
- Other duties as assigned.
KNOWLEDGE, SKILLS, ABILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- CDI Specialist must display teamwork and commitment while performing daily duties
- Must demonstrate initiative and discipline in time management and medical record review
- Advanced knowledge of Medicare Part A and familiar with Medicare Part B
- Intermediate knowledge of disease pathophysiology and drug utilization
- Intermediate knowledge of MS-DRG classification and reimbursement structures
- Critical thinking, problem solving and deductive reasoning skills
- Effective written and verbal communication skills
- Knowledge of coding compliance and regulatory standards
- Excellent organizational skills for initiation and maintenance of efficient workflow
- Capacity to work independently in a virtual office setting or at facility setting if required to travel for assignment
- Understand and communicate documentation strategies
- Recognize opportunities for documentation improvement
- Formulate clinically compliant credible queries
- Ability to maintain an auditing and monitoring program as a means to measure query process
- Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation
EDUCATION / EXPERIENCE
Include minimum education, technical training, and/or experience required to perform the job.
- Preferred: Graduate from a Health Information Management RHIT, RHIA, nursing degree and/or bachelor’s degree
- Preferred: Two (2) or more years relevant experience
CERTIFICATES, LICENSES, REGISTRATIONS
- Preferred: RHIT, RHIA, LPN, MD, AAPC, and/or CCS
- Preferred: CDIP or CCDS
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Ability to sit for extended periods of time
- Must be able to efficiently use computer keyboard and mouse
- Good visual acuity
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
OTHER
- Must be able to travel nationally as needed, not to exceed 10%
#J-18808-Ljbffr
