The Purpose of the Clinical Documentation Improvement (CDI) Specialist is to improve the overall quality and completeness of clinical documentation. The CDI Specialist reviews paper and electronic health records to ensure accuracy and complete documentation of all relevant diagnoses, procedures, and ancillary treatments.
The position requires a bachelor’s degree. A minimum of ten (10) years of experience in a healthcare organization are required. Must be able to demonstrate leadership ability and ability to communicate effectively orally and in writing. Familiarity with healthcare laws, regulations and standards. Understanding of coding and reimbursement systems, risk management and performance improvement is helpful.
DUTIES AND RESPONSIBILITIES:
* Reviews clinical documentation and facilitates modifications, as needed, to ensure that documentation accurately reflects the level of service rendered and severity of illness (in compliance with government and other regulations) for all patients.
* Maintains a system to identify admissions with specific diagnosis / DRG classifications or other categories of admissions.
* Initiates chart review within 24-48 of admission to meet criteria.
* Monitors, systematically, the targeted medical records (at least every 48 hours unless otherwise indicated) to determine compliance to established documentation standards.
* Notifies attending physicians and house staff officers or other disciplines promptly of chart deficiencies requiring clarification, with a preference for face-to-face communication where practicable.
* Conducts follow-up reviews to ensure points of clarification have been addressed/recorded in the patient chart.
* Maintains an ongoing record of the results of each chart review including responses to all interventions.
* Reviews the medical record post discharge to determine coding status.
* Compiles and Provides Timely Statistical Reports Including, but not limited to:
* Number of charts reviewed
* Number of charts with documentation deficiencies per physician
* Final DRG assignments
* Other pertinent data
* Facilitates the Ongoing Education of Staff in Chart Documentation Improvement Techniques and Practices.
* Provides periodic formal and informal in-service updates to medical staff and other disciplines using both one-on-one and group forums.
* Educates practitioners on a one on one basis.
* Develops and disseminates documentation improvement literature in conjunction with Medical Staff.
* Serves as a resource to Physicians / Case Managers and other key professional staff in matters relating to published DRG information.
* Works with medical records, finance and physician groups to develop systems to facilitate complete documentation for data reporting purposes.
* All other duties as assigned