HIM CDI Specialist, Remote

📋 Description

• • The HIM CDI Specialist plays a critical role in ensuring the accuracy and completeness of clinical documentation within patient medical records. This remote position is integral to the revenue cycle, focusing on concurrent review of inpatient records to facilitate modifications that accurately capture the clinical severity of illness and risk of mortality. This directly impacts the MS-DRG assignment, which translates into coded data and supports the appropriate level of service rendered.
• • You will be responsible for evaluating and reviewing inpatient medical records daily, typically within 24-48 hours of admission for a specified patient population. This proactive approach aims to identify opportunities to clarify missing or incomplete documentation, ensuring a comprehensive understanding of the patient's condition and treatment.
• • A key responsibility involves assigning the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment. You will also score the risk of mortality and severity of illness, initiating a review worksheet to document findings.
• • Regular follow-up reviews, conducted every 2-3 days, are essential to support and finalize the working MS-DRG assignment by the time of patient discharge.
• • You will formulate clinically compliant and credible physician queries to address missing, unclear, or conflicting health record documentation, requesting and obtaining additional information as needed.
• • Proactive collaboration with physicians is paramount. You will engage in discussions to clarify documentation inconsistencies, ensuring the medical record accurately reflects the patient's course of treatment and the complexity of care provided.
• • A significant aspect of this role involves educating providers on identifying disease processes that reflect severity of illness (SOI), complexity, and acuity. This education facilitates the accurate application of coding sets, leading to more precise data.
• • You will gather and analyze information pertinent to documentation findings and outcomes, using this data to develop action plans for process improvements within the CDI program.
• • Collaboration extends to case managers, nursing staff, and other ancillary teams. You will work with these groups to coordinate interactions with physicians regarding documentation opportunities and to resolve physician queries prior to patient discharge, streamlining the process and ensuring timely resolution.
• • The HIM CDI Specialist will communicate and complete Clinical Documentation Improvement (CDI) activities and address coding issues, such as lacking documentation or unresolved physician queries, ensuring appropriate follow-up and resolution with leadership.
• • Continuous professional development is a core expectation. You will stay abreast of the latest training in CDI, participate in ongoing staff development, and engage in continuing education activities to maintain certifications and licensures.
• • You will collaborate closely with HIM/coding professionals to review and resolve DRG mismatches for complex cases. This ensures the accuracy of final coded data, working in conjunction with CDI managers, coding managers, and/or physician advisors.
• • Identifying patterns, trends, variances, and opportunities to improve documentation review processes is crucial for enhancing the efficiency and effectiveness of the CDI program.
• • You will aid in the identification and proper classification of complication codes and present on admission (POA) determination, including patient safety indicators and hospital-acquired conditions, acting as a vital intermediary between coding staff and medical staff.
• • Contributing to a positive and collaborative working environment is expected, along with performing other duties as assigned to enhance the overall efforts and success of the organization.
• • This role requires a deep understanding of medical terminology, official coding guidelines, and federal, state, and private payer regulations. You will leverage your advanced clinical expertise and extensive knowledge of complex disease processes to excel in this position.
• • The ability to work independently, self-motivate, and adapt to the evolving healthcare landscape is essential for success in this remote role.
• • Strong analytical thinking, problem-solving skills, and meticulous attention to detail are necessary for accurately interpreting medical records and formulating queries.
• • Excellent organizational and planning skills are required to manage multiple tasks effectively in a fast-paced environment.
• • Proficiency in computer use, including database and spreadsheet analysis, presentation programs, word processing, and internet research, is fundamental to the daily operations of this role.
• • A working knowledge of quality improvement theory and practice, core measures, safety, and other required reporting programs will be utilized to contribute to organizational performance initiatives.