CDI Specialist - Health Information Management

Under direction of both the Director and CDI Manager, the Clinical Documentation Specialist independently prioritizes and performs assigned duties and tasks.

Clinical Documentation Specialists are responsible and accountable for the day-to-day management and success of the Continuous Documentation Improvement Project to include all modalities, acting as a liaison with specific department staff, speaking, meeting and educating physicians, residents and mid-levels, and assisting with the development and implementation of clinical documentation improvement processes. CDSs work in conjunction with Medical Coding, Case Management and other health team members to gather and analyze information in order to provide for comprehensive medical record documentation that accurately reflects clinical treatment, decisions, and diagnosis for inpatients. The Clinical Documentation Specialist utilizes clinical expertise and some coding knowledge to identify opportunities and ensure accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes, including quality measures. Physician queries are generated to assist and improve the quality of the documentation. CDSs also supply support to the Medical Coders, Quality staff and revenue cycle team in the complaint coding and processing of inpatient claims.

Required Experience:

Must have an RN or MD certification.

Minimum 5 years experience as CDS, some or all of which must be with an Academic Medical Center.

Be able to discuss medical diagnostic topics.

Be familiar with coding as it relates to documentation.

Have worked in an EPIC and 3M 360 Encompass (CAC) software environment.

Skills:

Ability to effectively communicate to physician/staff the necessity/appropriateness of clinical documentation.

Ability to effectively communicate to the payer the medical necessity/appropriateness /level of care criteria that is necessary for acute care hospitalization.

Skills in setting priorities that accurately reflect the relative importance of job responsibilities.

Skill in abstracting and interpreting medical information from patient records.

Working knowledge of laws, rules, and regulations regarding utilization review and discharge planning functions of government programs such Medicare, Medi-Cal, and CCS.

Clinical experience sufficient to understand and communicate medical diagnosis and courses of treatment to professional and non-professional personnel.