Description General Summary The Clinical Documentation Improvement (CDI) specialist is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. This position will be responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of services rendered. The CDI Specialist assesses clinical documentation through extensive review of the medical record, interaction with physicians, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate. Duties Notice The statements below describe the essential duties of the person or persons assigned to this job. They are not intended as an exhaustive list of all job duties and responsibilities. Principal Duties And Responsibilities Facilitates appropriate clinical documentation to support appropriate diagnosis coding and to ensure the level of service rendered to all patients is recorded. Collaborates with HIM coding staff to promote complete and accurate clinical documentation and to resolve documentation and coding discrepancies, ensuring accurate code assignment and clinical validation. Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation. Assigns a working MS-DRG or APR-DRG and severity level using coding rules and guidelines with follow up reviews as required by LOS standards. Analyzes clinical information to identify areas within the chart for potential gaps in physician documentation. Queries physicians on a concurrent basis. Works with physicians to clarify missing, ambiguous, or conflicting documentation in the medical record following the appropriate query guidelines. Formulates credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI). Conducts post discharge reviews for comparative analysis of CDI Specialist and HIM MS-DRG and/or APR-DRG and severity level assignment. Reviews clinical issues with the coding staff to assign a working DRG. Ensures that clinical documentation meets regulatory and compliance standards, including coding guidelines, and validates the clinical accuracy of documented conditions. Develops and conducts ongoing education for new staff, including new CDI Specialists, physicians and nursing, as applicable. Utilizes software systems (including MS-DRG and/or APR-DRG encoder) to collect, track, and report outcomes. Requires proficiency in abstracting and data entry into all databases used for clinical documentation. Maintains integrity of data collection. Participates in ongoing education of provider staff. Develops educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians presented as handouts, PowerPoint, etc. Requirements Minimum Knowledge and Skills Required Work requires the knowledge of theories, principles, and concepts typically acquired through completion of a Bachelor's Degree in Nursing. Minimum of five years recent, broad-based clinical experience in an inpatient acute care hospital is required. Knowledge of ICD-10 coding, as well as strong computer skills preferred, however content training in coding will be provided. Work requires superior interpersonal skills and demonstrated ability to communicate effectively with physicians primarily through written queries is essential. Certification, Registration, Or Licensure Required Registered Nurse with ICU or Med/Surg experience. AHIMA or ACDIS credentialed as CDIP or CCS a plus.