CDI Specialist

Clinical Documentation Improvement (CDI) specialists are responsible for improving the overall integrity of medical records documentation. Their responsibilities can vary based on an individual's specific job, company, or industry. Here are some general clinical documentation improvement specialist responsibilities.

CDI includes a review of disease process, diagnostic findings, and what documentation might be missing. A CDI specialist often has both clinical and medical coding backgrounds. Bridging the gap between clinical documentation and accurate coding drives CDI programs.

While reports from laboratory tests, diagnostic tests, and consultations with specialists may also be housed in a patient's medical record, clinical documentation in the context of CDI generally refers to the entries made by a provider.

While CDI may have gotten its start in the inpatient environment, outpatient providers have recognized the benefit and started programs, as well. The natures of inpatient and outpatient CDI programs vary, but they share a goal of increasing the accuracy of clinical documentation and coding.

Roles and responsibilities:

Applying knowledge of medical terminology and procedures to evaluate clinical documents.

Collecting medical information from healthcare providers and updating medical records.

Verifying the accuracy of patient medical information and obtaining missing information.

Facilitating and obtaining appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality.

Interacting directly with physicians to query for more specific documentation and to provide documentation guidelines from ICD-9 and ICD-10 standards.

Creating documentation education classes to general surgery residents, increasing the leveling of reporting which lead to increase revenues.

Clinically evaluate how the health record translates into coded data, including review of provider and other clinician documentation, lab results, diagnostic information, and treatment plans.

Communicate with providers either through discussion or in writing (e.g., formal queries) regarding missing, unclear, or conflicting health record documentation, and clarify the information as warranted.

Educate providers about identification of disease processes that reflect SOI, complexity, and acuity to facilitate accurate application of code sets.

Communicate with appropriate healthcare team members to promote accurate and complete documentation of diagnoses and/or procedures in the health record that have direct bearing on SOI.

Demonstrate an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record, as well as the ability to impart this knowledge to providers and other members of the healthcare team.

Gather and analyze information pertinent to documentation findings and outcomes and use this information to develop action plans for process improvements.

Qualifications:

Must be a RN Nursing or Any Medical Allied Course Graduate

Currently holds and maintain at least one certification: active PHRN License/active Medical Coding Certification (CCDS, or CCS, or CDIP, or CRCR)

Any RN minimum 2 years with Inpatient concurrent CDI experience. CCDS or CDIP certification is must.

With at least 3-5 years of Clinical Documentation Improvement Specialist experience

With at least 3-5 years Clinical/Hospital experience

Has experience with both MS-DRG and APR-DRG focused review.

Willing to train on-site.

Job Highlights:

Work Onsite (Ortigas, Pasig City)

Fixed Weekends Off

Competitive Salary package

Nontaxable Allowances

HMO on day 1 plus 1 free dependent