Job Description
CDI Specialist - Clinical Documentation Improvement Specialist
VA in Long Beach, CA
Collaboratively work with professional clinical staff and provides support and education on documentation issues.Role requires proficiency with ICD10.
Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that all information is fully documented and supported.
Ensure the accuracy of billing denials and prevention against fraud and abuse and to optimize the medical center's authorized reimbursement for utilization of resources provided.
Provide advice and guidance in relation to issues such as Documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, and state reporting.
Analyze situations or processes and recommends improvements or changes in documentation as deemed necessary.
May assist in writing coding protocol/policies which will reflect the required changes to enhance revenue through improved documentation.
Compile, review, abstract, analyze and interpret medical data incidental to a variety of patient care and treatment activities.
Conducts daily reviews of all new admissions to designated clinical services to identify those with potential documentation improvements through periodic evaluation during the patient's stay.
Reviews the health record and discusses the case with the clinical staff.
Performs admission reviews for specific patient populations to facilitate appropriate clinical documentation and ensures the level of services and acuity of care are accurately reflected in the health record.
Reviews the appropriateness of patient working Diagnosis Related Group (DRG) and length of stay information by reviewing all clinical documentation, lab results, diagnostic information and treatment to ensure documentation reflects severity of illness, acuity and resource consumption.
Participate in clinical rounds and may, where appropriate, offer information on documentation, coding rules and reimbursement issues.
The documentation specialist is a member of the healthcare team, and as such, shall assist all clinical providers with ICD, CPT and DRG methodologies so that documentation will more accurately reflect the occurrence of the encounter.
Maintain statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.
Strive for the optimal payment to which the facility is legally entitled, but it is deemed unethical and illegal to maximize payment by means that contradict regulatory guidelines, e.g. upcoding, DRG creep, etc.
Selection of the principal diagnosis and principal procedure, along with other diagnoses and procedures, must meet the definitions of the Uniform Hospital Discharge Data Set (UHDDS).
