Clinical Documentation Specialist

3 weeks ago


Louisville Kentucky, United States UofL Health Full time
Job Summary

The CDI Ambassador will play a crucial role in developing and maintaining physician and medical staff relationships, acting as a liaison between the CDI Specialists, HIM, and the hospital's medical staff to facilitate accurate and complete documentation for coding and abstracting of clinical data. This position requires a strong understanding of clinical documentation requirements, MS-DRG Assignment, case mix index (CMI) analysis, clinical disease classifications, major and non-major complications and comorbidities (MCCs or CCs), and quality-driven patient outcome indicators.

Responsibilities
  • Finalize unanswered open queries between CDI specialists and physicians.
  • Conduct initial medical record reviews of all inpatient patient accounts within 24-48 hours of admission to evaluate and review inpatient medical records daily, concurrent with patient stay, to identify opportunities to clarify missing or incomplete documentation.
  • Assign the principal diagnosis, pertinent secondary diagnoses, procedures for accurate MS-DRG assignment, score risk of mortality and severity of illness, and initiate a review worksheet.
  • Collaborate with the Quality department and physicians to identify and resolve documentation patterns and discrepancies.
  • Provide ongoing physician and medical staff education regarding documentation, queries, coding guidelines, clinical terminology, and coding updates to improve their understanding of severity, acuity, risk of mortality, and DRG assignment.
  • Develop and maintain documentation tip sheets to enhance accurate and complete documentation and coding.
  • Recommend changes to documentation templates and physician queries based on coding changes, regulatory modifications, and quality review findings.
  • Provide on-call service for physician and medical staff query questions and education.
  • Refer potential and identified HAC's (hospital-acquired conditions), PSI's (Patient Safety Indicators), and preventable hospital HARM's to the Quality department.
Qualifications
  • Bachelor's degree in Nursing, Healthcare Administration, or HIM required.
  • 3+ years of acute care experience as a RN or 3+ years inpatient coding experience.
  • Prior experience with 3M 360 Clinical Application and Cerner PowerChart preferred.
  • Active RN license (KY), RHIA, or possess an active (AHIMA) CCS or (AAPC) CPC-H or CIC certified coding credential required.
  • AHIMA CDIP or ACDIS CCDS clinical certifications required or if hired without, must obtain within 12 months of employment.


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