Clinical Documentation Integrity (CDI) Coordinator

The Clinical Documentation Integrity Coordinator is accountable for coordinating the processes and personnel responsible for concurrent review of physician and ancillary documentation to identify severity of illness, risk or mortality, and specificity and etiology of diagnoses while demonstrating adherence to appropriate documentation standards: facilitation of reimbursement at the level appropriate to patient health status and services provided.  Supports timely, accurate and compliant documentation of severity of illness, risk of mortality and utilization of resources while demonstrating adherence to recognized standards of patient care.  Provides ongoing education to physicians and staff regarding clinical documentation standards.  Coordinate the day-to-day operation and activities of the Clinical Documentation Integrity (CDI) program.  Provide education and support to the patient care team regarding documentation guidelines to produce an accurate and specific accounting of the care provided to patients.  Ensures compliance of regulatory requirements as related to CDI.

KEY RESPONSIBILITIES

Performed majority of the time:

·         Applies approved clinical criteria to monitor appropriateness of admissions and continued stays, and documents findings in 3M 360 Encompass.

·         Completes initial review of assigned patient records within two (2) business days of admission.

·         Follows up on each assigned record within established timeframe and continues through patient discharge and maintains documentation of all reviews performed.

·         Collaborate with coding/HIM regarding DRG assignment and documentation issues.

·         Initiates physician query when documentation is unclear, conflicting, missing or otherwise inadequate.

·         Through a variety of modalities, educates physicians in documentation requirements, and provides education to other members of the healthcare team regarding issues related to documentation.

·         Produces reports of program trends and CDI key indicators.

·         Assists in the collection and reporting of resource and financial indicators including case mix, length of stay (LOS), cost per case, excess days, resource utilization, readmission rates, denials and appeals.

·         Maintains familiarity with disease processes, available resources and treatment modalities, assessing their quality and appropriateness for specific disabilities, illnesses and injuries.

Performed occasionally but critical to successful performance of the job:

·         Reports suspected abuse, neglect, or unsafe discharge environment to the appropriate agency.

Decision making and budget responsibilities:

·         Decision making can impact the department operations.

·         No budget responsibilities.

Education:

Required

·         A copy of your highest academic diploma or transcript.

·         Registered Nurse, Inpatient Coder, or MD-equivalent

Preferred

·         CCDS or AHIMA credentialed as CDIP or CCS 

Experience:

Required

·         At least 3-5 years recent experience 1) in a variety of inpatient hospital clinical settings; or 2)  as an inpatient coder

·         Knowledge of ICD-10 coding

·         Minimum of 1 year CDI experience

Preferred

·         Experience as an inpatient medical coder.

Licenses, Certifications and/or Registrations:

Required

·         Current license can be in any state.

·         Certified Clinical Documentation Specialist from ACDIS and/or Clinical Documentation Integrity Practitioner from AHIMA required within three (3) years of hire date.

Preferred

·         Medical Doctor, Nurse Practitioner, Physician Assistant, Coder (Certified Coding Specialist, Registered Health Information Technician, Registered Health Information Administrator).

Job Related Skills, Abilities and Behaviors:

Required

·         Works collaboratively and maintains active communication with physicians, nursing and other members of the multi-disciplinary care team to effect timely, appropriate patient management.

·         Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.

·         Demonstrates an understanding of insurance policy language and various health care options.

·         Develops and maintains collegial relationships with other professionals by attending continuing education and professional group sessions.

·         Demonstrates ethical commitment to quality assurance and confidentiality of all data and information.

·         Excellent customer service skills.

·         Emulates the organization’s dress code and Code of Conduct that incorporates presenting a good first and lasting impression through personal appearance and interpersonal skills.

·         Experience working in highly confidential settings.

·         Possesses excellent telephone skills and interpersonal communication abilities both verbal and written.

·         Strong computer skills including word processing, database, and spreadsheet programs.

·         Self-directed and able to follow through on projects with attention to detail and implement ideas and programs with minimal supervision.

·         Demonstrates creativity, flexibility and the ability to work under stress.

Preferred

·         Bilingual skills a plus.