Clinical Documentation Improvement Spec.


Bismarck, ND

Industry: Healthcare


Less than 5 years

Posted 172 days ago

This job is no longer available.

Educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management. Assist with overseeing department workflow and metrics. Create reports used to make strategic decisions. Educate and train department staff. Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians* clinical documentation.


Include the following. Others may be assigned.

Record Review:

* Completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and sevirty of illes; and (b) initiate a review worksheet.

* Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary.

* Formulate physician queries regarding missing, unclear or confliting health record documentation by requesting and obtaining additional documentation within the heatlh record, as necessary.

* Collaborates with case managers, nursing staff and other ancillary staff regarding interaction with physicians regarding documentation and to resolve physician queries prior to discharge.

Lead Responsibilities:

* Provides daily support/mentoring/training to new hires as well as existing staff.

* Provides assistance in managing escalated issues and special projects as needed to supervisors and managers. CDI staff coverage

* Performs concurrent and retrospective CDI audits

* Provides CDI support/mentoring/training to Physicans and hospital leadership as needed.

* Completion of scrubbing and submitting monthly data to vendor

* Enters facility specific data to dashboards

* Resolves problems, concerns and reports issues with Operations Supervisor, Manager or Director.

Professional Development:

* Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-9-CM and CPT coding.

* Attends mandatory coding seminars on annual basis (IPPS and OPPS, ICD-9-CM and CPT updates) for inpatient and outpatient coding.

* Quarterly review of AHA Coding Clinic.

* Attends Quarterly Coding Updates and all coding conference calls as well as any required CDI education.


* Communicates/Completes Clinical Documentation Improvement (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolution

Other duties as assigned



To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

    Must display teamwork and commitment while performing daily duties
    Must demonstrate initiative and discipline in time management and medical record review
    CDI Subject Matter Expert with Advanced knowledge of Medicare Part A and familiar with Medicare Part B
    Intermediate knowledge of disease pathophysiology and drug utilization
    Intermediate knowledge of MS-DRG classification and reimbursement structures
    Critical thinking, problem solving and deductive reasoning skills
    Effective written and verbal communication skills
    Knowledge of coding compliance and regulatory standards
    Excellent organizational skills for initiation and maintenance of efficient work flow
    Capacity to work independently in a virtual office setting or at facility setting if required to travel for assignment.
    Understand and communicate documentation strategies
    Recognize opportunities for documentation improvement
    Formulate clinically, compliant credible queries
    Ability to maintain an auditing and monitoring program as a means to measure query process
    Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation
    Must be able to resolve issues effectively and provide recommendations and solutions
    Effectively explain processes and teach others to follow them
    CDS SME with ongoing education with physicians and facility leaders
    CDI facility representation for hospital and physician meetings
    Local facility mentorship for CDI team support and effectiveness
    Facility schedule review to ensure units needs covered per P&P
    CDI staff coverage
    Gathering additional data as needed for supervisor, manager and director


Include minimum education, technical training, and/or experience required to perform the job.
    Preferred: Three (3) or more years experience in CDI
    Graduate from a Nursing program, BSN, or graduate of Health Information Management RHIT, RHIA preferred
    Preferred: Two (2) years experience with either HIM/Coding or Case Management experience.
    Required:  RN, or RHIT, RHIA, and/or CCS
    Preferred: CDIP or CCDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

    Ability to sit for extended periods of time
    Must be able to efficiently use computer keyboard & mouse to perform CDI functions
    Good visual acuity


The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Must be able to travel regionally as needed, not to exceed 10%

Security Clearance Required: No

Visa Candidate Considered: No


Base Salary - $80,500 to $88,000

Full-time Benefits - Full

Relocation Assistance Available - No

Commission Compensation - No

Bonus Eligible - No

Overtime Eligible - No

Interview Travel Reimbursed - No


2+ to 5 years experience

Seniority Level - Associate

Management Experience Required - No

Minimum Education - Bachelor's Degree

Willingness to Travel - Occasionally