Position Overview
The client is seeking an experienced Clinical Documentation Integrity (CDI) Specialist to perform concurrent reviews of inpatient medical records. This role focuses on ensuring that the patient's severity of illness, acuity of care, diagnoses, procedures, and treatments are accurately and completely reflected in the medical record.
The CDI Specialist will work closely with physicians, Coding, Quality, and other members of the healthcare team to identify documentation opportunities, initiate compliant provider queries, and support accurate coding and quality reporting.
Key Responsibilities
- Perform concurrent reviews of inpatient medical records for documentation accuracy and completeness.
- Identify documentation opportunities related to severity of illness, acuity, diagnoses, procedures, and treatments.
- Initiate compliant physician/provider queries for clarification and specificity.
- Follow up on outstanding queries to support completion prior to patient discharge.
- Review and update CDI/DRG information based on changes in the patient's clinical status.
- Validate the principal diagnosis (PDx), DRG, and supporting clinical documentation.
- Collaborate with physicians, Coding, Quality, and multidisciplinary healthcare teams.
- Provide education regarding clinical documentation opportunities that impact acuity, quality, and coding.
- Maintain current knowledge of CDI guidelines, practices, and compliant query standards.
- Provide coverage for other CDI Specialists as needed.
Required Qualifications
- Active Registered Nurse (RN) license required.
- 3+ years of acute-care hospital nursing experience, with critical care experience such as ED, Trauma, or ICU strongly preferred.
- 2+ years of Clinical Documentation Integrity (CDI) experience preferred/required.
- Candidates with 5 years of acute-care nursing experience, including 3 years of critical care, may be considered in lieu of 2 years of CDI experience.
- CCDS or CDIP certification preferred. Candidates who are not currently certified must be able to obtain CCDS or CDIP after meeting eligibility requirements.
- Strong understanding of inpatient clinical documentation, provider queries, principal diagnosis, and DRG review.
- Experience with Epic and 3M 360 preferred.
- Previous experience working remotely preferred.
- Strong critical-thinking, analytical, communication, and organizational skills.
Ideal Candidate
The strongest candidate will be an RN with hands-on inpatient CDI experience who is comfortable independently reviewing concurrent charts, identifying documentation gaps, communicating with physicians, issuing compliant queries, and validating principal diagnosis and DRG assignment.
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