Department: Medical Information Services
Schedule: Full Time
Shift: Day
Hours: 8
Job Details:
  • Clinical Documentation Improvement Specialist will provide concurrent review of clinical documentation in medical record. The reviewer will include a thorough review to identify comorbidities and complications and clinical findings. The specialist will be responsible for writing queries to the medical staff and meet face to face with physicians to discuss care provided/clinical documentation that may support care given for severity of patient illness/risk of mortality. All efforts will also be made to capture documentation in the medical record for all appropriate secondary diagnoses for quality ratings and physician profiling. Specialist will be responsible for conducting initial, extended stay concurrent reviews on selected admissions and conduct follow-up on unanswered queries within a timely manner. They will also be responsible for working with coding team on discharged queries. Clinical Documentation Improvement Specialist also will be responsible for providing information and informal in-services to physicians and ancillary staff. The CDI team will be expected to meet on a regular basis with the coding team to review monthly reports for operational, financial, compliance and quality rating impact for the facility, discuss coding clinic’s, share clinical knowledge and discuss process improvements for team. Team member will work independently, with the other CDI team members, coders, physicians, nurses and Director, HIM. They must have good organizational, time management, interpersonal and communication skills.

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