CDI Specialist - Health Information Management ( On-Site)

1. Completes initial review(s) of patient records within 48 hours of admission for a specified patient population.
2. Evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality and severity of illness and initiate a review worksheet.
3. Conducts follow-up reviews of patients to support and assign a working or final DRG assignment upon patient discharge.
4. Queries physicians regarding missing, unclear or conflicting health record documentation by requesting and obtaining additional documentation within the health record.
5. Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record or documentation and to resolve physician queries prior to patient discharge.
6. Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership to identify opportunities for improvement and facilitates change processes required to capture needed documentation.
7. Collaborates with case managers, nursing staff and other ancillary staff regarding interaction with physicians.
8. Educates members of the patient care team regarding specific documentation needs, reporting and reimbursement issues identified through daily documentation reviews and aggregate data analysis.
9. Partners with the coding professionals to ensure accuracy of diagnostic, procedural data, completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality.
10. Other duties as assigned.

Requirements:

Bachelor's degree in healthcare nursing, medical or health information management.

CCS, CDIP, CDIS, RN, MD, RHIT, or RHIA required.

Previous experience as a CDI in an acute care facility.