CDI Specialist Job Listing at MedStar Medical Group in Olney, MD (Job ID req39001)

Description

Ensures that documentation supports accurate, complete and consistent, unambiguous clinical documentation. Utilizes clinical expertise to support appropriate reflection of the patient's risk of mortality and severity of illness. Develops compliant physician queries guided by the American Health Information Management Associations (AHIMA) Ethical Standards for Clinical Documentation Improvement Professionals, the ACDIS/AHIMA Query practice brief, and state, federal, and other appropriate regulatory guidance. Evaluates the medical records for case specific review including mortalities, complications, quality of care, and other needs identified requiring review and/or second level review. Reviews and analyzes inpatient record for compliant documentation. Provides education to all levels of clinical staff. Closely collaborates with coding professionals to ensure appropriate ICD-10 and DRG assignment. Maintains certification and credentials applicable to the Clinical Documentation Integrity Specialist role. Monitors clinical case data to identify areas of improvement.
Education

• Associate's degree in Nursing preferred or
• Bachelor's degree in Nursing preferred or
• Master's degree Nursing or other clinically focused field of study such as Advanced Practice Nursing, Physician Assistant preferred or
• Doctoral degree Foreign Medical Graduate preferred

• 3-4 years Experience in acute care setting required and
• Experience in ICD-10 coding review and DRG reimbursements systems preferred

• Cert Docum Improv Practitioner - CDIP within 2 years required or
• CCDS - Certified Clinical Documentation Specialist within 2 years required and
• CCS-Certified Coding Specialist preferred

• Proficient in Microsoft Office applications (Word, Excel, PowerPoint).
• Excellent interpersonal skills, including verbal and written communication.
• Ability to collect and analyze data related to the CDI program.
• Proficient in reviewing medical records and understanding pertinent clinical information.
• Ability to demonstrate critical-thinking skills.