General Summary 

The Clinical Documentation Improvement (CDI) specialist is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. This position will be responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of services rendered. The CDI Specialist assesses clinical documentation through extensive review of the medical record, interaction with physicians, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate.?  

Location 

This position will be remote.  Minimal travel may be required. 

Principal Duties and Responsibilities 

1. Facilitates appropriate clinical documentation to support appropriate diagnosis coding and to ensure the level of service rendered to all patients is recorded. 
2. Collaborates with HIM coding staff to promote complete and accurate clinical documentation and correct negative trends.  
3. Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation.? 
4. Assigns a working APR-DRG and severity level using coding rules and guidelines with follow up reviews as required by LOS standards. 
5. Analyze clinical information to identify areas within the chart for potential gaps in physician documentation. 
6. Queries physicians on a concurrent basis. Works with physicians to clarify documentation in the medical record. 
7. Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI). 
8. Conducts post discharge reviews for comparative analysis of CDI Specialist and HIM APR-DRG and severity level assignment. Reviews clinical issues with the coding staff to assign a working DRG. 
9. Develops and conducts ongoing education for new staff, including new CDI Specialists, physicians and nursing. 
10. Utilizes software systems (including APR-DRG encoder) to collect, track, and report outcomes.  Requires proficiency in abstracting and data entry into all databases used for clinical documentation.  Maintains integrity of data collection. 
11. Participates in ongoing education of staff.  Develops educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians presented as handouts, PowerPoint, etc. . 

Minimum Knowledge and Skills Required 

1. Work requires the knowledge of theories, principles, and concepts typically acquired through completion of a Bachelor’s Degree in Nursing. Minimum of five years recent, broad-based clinical experience in an inpatient pediatric setting required.  
2. Knowledge of ICD10 coding, as well as strong computer skills preferred, however content training in coding will be provided.  
3. Work requires superior interpersonal skills and demonstrated ability to communicate effectively with physicians is essential.  

Certification, Registration, or Licensure Required 

Required: 

• Active Accreditation as a CDIS or CCDS by either AHIMA or ACDIS  
• Active RN (Preferred) or MD-Equivalent (Acceptable). CCS registration a plus. 
• At least two years of experience performing CDI reviews and related activities.