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CDI Specialist

Children's Healthcare of Atlanta

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The Clinical Documentation Improvement Specialist (CDIS) will facilitate and obtain concurrent physician documentation for any clinical conditions or procedures which support the appropriate severity of illness, expected risk of mortality, and the complexity of care of the inpatient population.  This individual exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions and procedures for the pediatric patient population.  This individual also educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing staff, and case management.

 

 

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES:
  1. Completes initial and subsequent concurrent reviews of pediatric inpatient medical records in accordance with established timelines, in order to promote accurate code and DRG assignment and assessment of risk of mortality and severity of illness. 
  2. Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation in the health record when needed.
  3. Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation issues and strives to resolve physician queries prior to patient discharge.
  4. Reviews and clarifies clinical issues in the health record with the coding professionals to support accurate DRG assignment, severity of illness, and/or risk of mortality.
  5. Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
  6. Supports and participates in the continuous assessment and improvement of the quality of services provided.
 MINIMUM QUALIFICATIONS:
  • Graduate of an approved Health Information Technology/Management program with credentials of RHIA, RHIA eligible, RHIT, RHIT eligible, CCS, CCS-P and/or graduate from an accredited nursing program with RN licensure.
  • A health information management professional with at least 5 years of inpatient coding experience and/or an RN with at least 5 years acute care nursing experience (e.g., medical-surgical, ICU, case management, etc.) is preferred.
  • Strong knowledge base in complete and accurate clinical documentation in all healthcare settings and for all healthcare disciplines.
  • Strong knowledge base and experience in interpreting and applying federal/government regulations to ensure coding and documentation compliance
  • Strong knowledge base of the conventions, rules and guidelines for multiple classification and reimbursement systems (i.e. ICD -10, DRGs, APR-DRGs, etc).
  • Ability to establish rapport with physicians and other healthcare practitioners.
  • Demonstrated knowledge of medical terminology, anatomy and physiology, pharmacology, computers, and encoding software. 
  • Demonstrated interpersonal, critical thinking, and time management skills.
  • Strong communication, teaching and presentation skills; must be detail oriented, possess good problem solving skills, and have legible handwriting.
  • Must be able to successfully pass the Basic Windows Skill Assessment at 80% or higher rating within 30 days of date of hire.

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