CDI Specialist I
- Location: Phoenix, AZ
- Posted: Sep 9, 2019
The Clinical Documentation Integrity (CDI) Specialist is accountable for reviewing patient medical records in the inpatient and/or outpatient setting to capture accurate representation of the severity of illness and facilitate proper coding. The CDI Specialist validates that coding reflects medical necessity of services and facilitates appropriate coding which provides an accurate reflection and reporting of the severity of the patient's illness along with expected risk of mortality and complexity of care. Documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care. Utilizes advanced knowledge of disease processes (pathophysiology), medications, and have critical thinking skills to analyze current documentation to identify gaps. Identifies opportunities in concurrent and retrospective inpatient clinical medical documentation to support quality and effective coding. Understands and applies regulatory compliance related to documentation, coding and billing for all health insurance plans. The CDI Specialist facilitates appropriate modifications to documentation through extensive interactions and collaboration with physicians, coding, case management, nursing and other care givers. Serves as an effective change agent as an educator and resource for physicians and allied health staff to improve the quality and completeness of the clinical documentation. Performs all duties and responsibilities in accordance with ethical and legal business procedures, compliant with federal and state statutes and regulations, official coding rules, guidelines and accepted standards of coding practice including appropriate clinical documentation policies.
Entry-level or minimal experience in a Clinical Documentation Integrity Specialist (CDIS) role and must have the Certified Clinical Documentation Specialist (CCDS) or the Certified Documentation Improvement Practitioner (CDIP) certification] and:
Any of the following: Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician-based (CCS-P), Registered Nurse (RN), completion of international or domestic medical program or, Formal education (accredited college-level course work) in human anatomy and physiology, medical terminology, and disease process or, Associate's degree or higher (candidates must also have completed coursework in medical terminology and anatomy and physiology).
- Full Time