Responsible for improving the overall quality and completeness of clinical documentation in the medical record to reflect the severity of illness, clinical treatment, decisions and diagnoses of patients.
Involves concurrent medical record review, DRG validation, querying providers, capture of clinical and quality indicators to ensure the thoroughness of documentation prior to coding and billing.
Responsible for the day-to-day review and evaluation of clinical documentation by the Medical Staff and healthcare team in accordance with the network's designated clinical documentation policies and procedures.
Calculates working DRG within CDI tracking systems/software.
Performs follow-up on cases through patient discharge.
Applies clinical knowledge and experience to the daily review and evaluation of the medical record including physician/clinical documentation, lab results, diagnostic information and treatment plans.
Promotes integrity of clinical documentation and thoroughness of the medical record to ensure appropriate severity of illness, risk of mortality, length of stay and reimbursement are captured.
Communicates with providers via verbal and/or electronic clinical documentation integrity queries to clarify missing, unclear or conflicting medical record documentation; identifies opportunities for service line and individual provider education and communicates to CDI leadership.
Achieves key performance indicators in the areas of productivity/thoroughness and quality.

Bachelor’s Degree BSN, RHIA or Master’s Degree CRNP, PA-C or Associate’s Degree RN, RHIT or Specialized Diploma RN, CCS, CPC
5 years advanced coding or clinical experience in an acute care hospital setting or 1 year CDI or coding experience
Experience with medical record reviews and/or DRG validation
Proficient in MS Outlook, Word, Excel and PowerPoint
Ability to acquire working knowledge of DRG assignment and methodology, coding practices and clinical documentation requirements
Will demonstrate adaptability and self-motivation to stay abreast of CMS rules and regulations; incorporate those changes into daily practice; maintain knowledge of federal, state and private payor regulations and demonstrate knowledge and understanding of ICD-10 Coding Guidelines.
Will demonstrate accountability, professional development, and adhere to departmental policies and guidelines.
RHIT
Registered Health Information Technician
American Health Information Management Association Upon Hire or RN
Licensed Registered Nurse_PA
State of Pennsylvania Upon Hire or RHIA
Registered Health Information Administrator
American Health Information Management Association Upon Hire or CPC
Certified Professional Coder
American Academy of Professional Coders Upon Hire or CCS
Certified Coding Specialist
American Health Information Management Association Upon Hire

Clinical Documentation Specialist

Key skills