Company
Healthcare
HIMCDISpecialist
“HIM CDI Specialist. Skills: Clinical documentation improvement, MS-DRG assignment, Physician query formulation. Review patient medical records. Facilitate modifications to clinical documentation”
Industry & Context.
Analytical thinking; Problem solving
What They're Looking For.
Must Have
RN, RHIA, RHIT or CCS/CPC-H credential, 3+ years acute care experience as RN, 3+ years inpatient coding experience, Advanced clinical expertise, Extensive knowledge of complex disease processes, Broad clinical experience in inpatient setting
Nice to Have
Certified Clinical Documentation Specialist or Clinical Documentation Improvement Professional (CCDS or CDIP) credential within 12 months of employment
What You'll Do.
Review patient medical records
Facilitate modifications to clinical documentation
Interact with providers
Promote accurate capture of clinical severity
Support level of service rendered
Evaluate inpatient medical records daily
Identify opportunities to clarify documentation
Assign principal diagnosis
Assign pertinent secondary diagnoses
Assign procedures for MS-DRG assignment
Score risk of mortality
Score severity of illness
Initiate review worksheet
Conduct follow-up reviews
Assign working MS-DRG assignment
Assign final MS-DRG assignment
Formulate physician queries
Request additional documentation
Collaborate with physicians
Clarify documentation inconsistencies
Educate providers on disease processes
Gather documentation findings
Analyze documentation outcomes
Develop action plans for process improvements
Collaborate with case managers
Collaborate with nursing staff
Collaborate with ancillary staff
Resolve physician queries prior to discharge
Complete Clinical Documentation Improvement activities
Complete coding issue follow-up
Conduct CDIS staff development
Participate in continuing education
Review DRG mismatches
Resolve DRG mismatches
Identify documentation review process patterns
Identify documentation review process trends
Identify documentation review process variances
Identify opportunities to improve documentation review processes
Aid in identification of complication codes
Aid in classification of complication codes
Determine present on admission (POA)
Act as intermediary between coding and medical staff
Contribute to positive working environment
Perform other duties as assigned
How You'll Work.
Team & Collaboration
Internal customers; Revenue cycle team members; Case managers; Nursing staff; Ancillary staff; HIM/coding professionals; Physician advisors
Communication Scope
Physician queries; Provider education
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