Cdi Rn Specialist

**JOB SUMMARY**

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. Exhibits a sufficient knowledge of clinical documentation requirements, MS-DRG Assignment, and clinical conditions or procedures, Educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management.

**ESSENTIAL DUTIES AND RESPONSIBILITIES**
- 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 severity of illness; 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 conflicting health record documentation by requesting and obtaining additional documentation within the health 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. _**:

- **_Assist in training department staff new to CDI_**:

- **_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. _**:

- **_CDI: 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_**

**KNOWLEDGE, SKILLS, ABILITIES**
- 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._
- CDI Specialist must display teamwork and commitment while performing daily duties
- Must demonstrate initiative and discipline in time management and medical record review
- Travel may be required to meet the needs of the facilities
- _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_
- _Regular and reliable attendance and time reporting per Conifer Telecommuting program requirements_
- _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

**EDUCATION / EXPERIENCE**
- Include minimum education, technical training, and/or experience required to perform the job._
- Preferred: Acute Care nursing relevant experience
- Zero (0) to two (2) years experience
- Graduate from a Nursing program, BSN, or graduate

**CERTIFICATES, LICENSES, REGISTRATIONS**
- Active state Registered Nurse license
- Preferred: CDIP or CCDS

**PHYSICAL DEMANDS**
- 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 and mouse _
- Good visual acuity

**WORK ENVIRONMENT**
- 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