Type: Full-Time (75 hours biweekly)
Shift: Days
Hours: Varies
Salary: $86,000
POSITION SUMMARY:- Possesses strong clinical foundation with respect to differential diagnoses, disease interactions, pathophysiology, and treatment protocols
- Demonstrates mastery of ICD-10-CM/PCS coding guidelines
- Serves as liaison between providers and coders, with respect to crosswalk between clinical language and coding terminologies
- Educates provides on clinical documentation best practices aligned with ICD-10-CM/PCS Official Guidelines for Coding and Reporting
- Performs audits of medical records to ensure that provider documentation is accurate and complete and that correct ICD-10-CM/PCS codes are captured
- Fosters collaborative relationships with Hospital Leadership, providers, clinical teams, quality teams, compliance teams, and coding team
- Displays excellent oral and written communication skills
- Demonstrates proficiency developing and delivering presentations for training and education
- Demonstrates proficiency with DRG grouper software and electronic health records (e.g., Meditech, Epic)
ESSENTIAL FUNCTIONS: - Demonstrates qualities outlined in the "Customer Service Standards of Excellence" program when interacting with patients, their families and friends, and fellow employees
- Maintains compliance with internal and external policies, procedures, regulations, industry guidelines and objectives, HIPAA and safety standards
- Develops, coordinates and performs internal auditing activities, to ensure compliance with best practices for clinical documentation and coding
- Collaborates with inpatient coders to support accurate APR-DRG and MS-DRG assignment
- Writes clinical appeal letters and supports denial management process
- Generates clinically robust queries for providers and adheres to AHIMA Guidelines for Achieving a Compliant Query Practice
- Communicates with providers to obtain timely and compliant query responses
- Tracks, analyzes and trends data to identify opportunities for performance improvement
- Monitors, tracks and maintains key CDI metrics
- Educates providers on documentation best practices to ensure the most appropriate and specific ICD-10-CM/PCS codes are captured in accordance with State, Federal and other accrediting agencies
- Collaborates with interdisciplinary teams to identify opportunities and establish a unified approach for clinical documentation review, audit and education
- Collaborates with Clinical Applications department to create and implement EMR components for complete and accurate provider clinical documentation and appropriate APR-DRG and MS-DRG assignment
- Designs and presents CDI program metrics to Hospital Leadership
- Leads and/or participates in meetings pertaining to CDI
EDUCATION:Requirement for one of the following:
- MD: Medical Doctor
- DO: Doctor of Osteopathy
- MBBS/ECFMG Certified
CERTIFICATION:Requirement for at least one of the following:
- AHIMA Certified Documentation Improvement Practitioner (CDIP)
- ACDIS Certified Clinical Documentation Specialist (CCDS)
- AHIMA Certified Coding Specialist (CCS)
EXPERIENCE:- 5+ years inpatient CDI experience.
- 3+ years clinical experience managing patients in acute care setting
