CDI Specialist

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CDI needed

Provides thorough concurrent review of medical record clinical documentation to capture documented and potential principal diagnosis, secondary diagnoses and procedures affecting DRG assignment and profiling outcomes. Queries the medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports DRG assignment and the severity of patient illness and risk of mortality.
Qualifications (Outline of only the minimum requirements for the job code)
Minimum Education: High School Diploma or Equivalent
Minimum Years of Experience: 3 Years of Clinical Experience in an Acute Care Setting
Certification from either AAPC (Certified Documentation Expert – Inpatient CDEI), ACDIS (Certified
Clinical Documentation Specialist (CCDS), or AHIMA (Certified Documentation Improvement
Practitioner (CDIP). Those Without One of the Above Will be Considered, But Must Obtain an Eligible Certification from One of These Entities Within the First Year of Entry into Role.

Job Description
Duties and Responsibilities (High-level summary of activities encompassed by job code within organization)
1 . Collaborates with physician, physician extender, nurse, case manager/utilization reviewer and Medical Records coder to identify principal diagnosis options, secondary diagnoses and  procedures, to assign working DRGs for identified populations. 
2.    Conducts initial and extended-stay concurrent reviews on all selected admissions and documents findings denoting all key information utilized in the tracking process.
3.    Identifies need to clarify documentation in records. Utilizes strong communication skills with physician, physician extender, case manager, utilization reviewer, nurse or other healthcare professionals, utilizing appropriate tools to capture needed documentation. Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient’s severity of illness and risk of mortality.
 4. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data.
5. Performs all other duties as assigned.
 
Location: remote,
Type: Contract
Pay: Apply for details

1590

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