The Clinical Documentation Integrity (CDI) Specialist collaborates with physicians, nursing staff, other patient caregivers, and medical records coding staff to improve the quality, specificity, accuracy, and completeness of documentation of care provided and coded.
The role reviews medical records for opportunities for diagnosis clarification and validity as it relates to DRG assignment, severity of illness, risk of mortality, and case mix data, along with clinical indicators such as HACs, PSI, and mortality metrics. The position follows coding and clinical documentation improvement guidelines endorsed by ACDIS and AHIMA, as well as company policies and procedures.
Responsibilities include conducting clinical documentation reviews and audits, analyzing query opportunities, responding to compliance-related inquiries, and supporting reconciliation of CDI-reviewed charts. Periodic travel may be required.
Required qualifications include:
- Recognized CDI credential from ACDIS (CCDS)
- Current RN license
- Current AHIMA or AAPC coding credential preferred
- 3+ years of experience working as a clinical documentation specialist
- 3+ years of clinical experience in an acute care setting
Additional skills and abilities:
- Strong analytical skills and ability to work with numbers
- Ability to work with multiple and diverse clients and projects
- Ability to work independently with minimal supervision
- High level of accuracy and attention to detail
- Professional communication and teamwork skills
- Ability to maintain confidentiality and adhere to HIPAA guidelines
- Commitment to continuing education and professional development
Location
South Carolina, US
Employment Type
Full-time
Experience Level
Senior
Remote work allowed
No
Posted
2 weeks ago