Clinical Documentation Integrity (CDI) Specialist for a full-time day shift role within an acute care healthcare system.
The CDI Specialist serves as a liaison between physicians and hospital departments to improve documentation consistency, data quality, compliance, and accurate DRG assignment. This role supports concurrent chart review, clinical validation, query processes, and collaboration with HIM and Coding teams to ensure records accurately reflect patient severity of illness, risk of mortality, and reimbursement impact.
Key responsibilities include:
- Perform concurrent documentation reviews to support initial DRG assignment and case management follow-up.
- Collaborate with physicians and clinical staff to improve completeness and accuracy of inpatient documentation.
- Monitor inpatient admissions for length of stay, working DRGs, SOI/ROM, and final coding impact.
- Prepare reports and maintain productivity and effectiveness data related to CDI activities.
- Support quality measures including HACs, PSI, and POA indicators.
- Serve as a resource on ICD-10-CM and ICD-10-PCS coding guidelines and medical terminology.
- Work with HIM and Coding departments to validate DRGs and resolve documentation issues.
- Issue concurrent queries when documentation is incomplete or clinically unclear.
- Assist with post-discharge queries as needed.
- Educate physicians on coding versus clinical documentation issues.
- Identify opportunities for operational improvement and compliance enhancement.
- Monitor audits, denials, and trends to reduce recurring documentation issues and financial risk.
- Maintain awareness of regulatory, coding, and reimbursement changes.
- Reconcile discharge and coded records to ensure queries are answered and results are accurately assigned.
Requirements & Qualifications
Qualifications
- Four or more years of coding experience or relevant work with health systems in acute care or outpatient settings.
- RN or equivalent advanced clinical licensure required.
- Willingness to obtain CDI certification within two years of hire, if applicable.
- CCS certification may be substituted for employees hired prior to September 2025.
- Graduate from an accredited HIM program preferred.
- Strong interpersonal, written, and verbal communication skills.
- Excellent organization, prioritization, analytical, and computer skills.
Location
Tennessee, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
No
Posted
2 weeks ago