Job Description

General Summary of Position
With minimal supervision from the Manager of Admissions and Clinical Resource Management, the CDI Specialist facilitates the modification of the clinical documentation through concurrent interactions per the Medicare Guidelines, with the healthcare team- prior to billing. They promote the capturing of the clinical severity of illness (SOI) which is then converted to coded data to support the level of service that is rendered to the patient The CDI specialist queries the healthcare team and the physicians on cases where additional documentation is needed to support the severity of the patient's condition and overall accuracy of the medical record; focusing on the accuracy, completeness and consistency of inpatient clinical documentation to support appropriateness and necessity based on information contained in the medical record.

Primary Duties and Responsibilities

• Review inpatient medical records on a daily basis, concurrent with patient stay to identify opportunities to clarify missing or incomplete documentation. Validates and verifies through documentation the most accurate Impairment code and the primary diagnoses.
• Collaborate with providers, case managers, coders and other healthcare team members to facilitate comprehensive health records documentation that reflects clinical treatment, decisions, diagnoses and interventions.
• Demonstrates and understands the capturing of complications, comorbidities, severity of illness, case mix and it's impact on billing.
• Assures the accuracy of quality measures in the IRF-PAI.
• Utilizes the hospital's designated clinical documentation system to conduct reviews of the health records and identifies opportunities for clarification.
• Conducts follow-up of posted queries to ensure that the queries have been answered and the physician response has been appropriately documented.
• Educates healthcare providers about identification of disease process that reflects the severity of illness (SOI), complexities and acuity in order to facilitate accurate application of compliant code sets.
• Acts as a consultant to coding professionals when additional information or documentation is needed to assign coded data.
• Collaborates with HIM, coding professionals and physician advisors to review individual problematic case and assures accuracy of final code.
• Gathers and analyze information pertinent to documentation findings and outcomes.
• Identifies patterns, trends, variances and opportunities to improve the documentation process.
• Conducts independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends and healthcare economics.

Minimum Qualifications
Education

• Bachelor's degree in Nursing or in Allied Health required
• degree in Allied Health. required
• Master's degree preferred

Experience

• 3-4 years Clinical experience, preferably in an acute inpatient rehabilitation care setting. required
• Must understand the strategic integration of clinical coding and reimbursement requirements. required
• Knowledge of PPS regulations and coding for acute inpatient rehabilitation. preferred

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure allied health license issued by the state required at the time of hire. required
• Certified Coder (CPCODER)-AHIMA or AAPC Must become AHIMA or ACIS certified in CDI within 12 -24 months of becoming eligible for the exam, within 2 years required
• CDIP - Clinical Documentation Improvement Professional CDIP or CCDS preferred and
• CRRN - Certified Rehabilitation Registered Nurse CRRN preferred, if Registered Nurse. preferred

Knowledge, Skills, and Abilities

• Proficient in reviewing medical records and understanding pertinent clinical information.
• Ability to demonstrate critical-thinking skills.
• Must have thorough understanding of the process of rehabilitation, expert physical assessment and patient/family/education skills.
• Proficient in Microsoft Office applications (Word, Excel, PowerPoint).

This position has a hiring range of $72,758 - $130,041

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