EM CDI Specialist

Role Overview: As an Emergency Medicine Clinical Documentation Improvement (EM-CDI) Specialist, your primary responsibility will be to enhance the quality and accuracy of clinical documentation within the Emergency Medicine department. You will play a crucial role in ensuring compliance with regulatory standards, optimizing reimbursement, and improving patient care outcomes. Collaboration with various healthcare professionals will be key to accurately reflecting patients" clinical conditions and treatments. Key Responsibilities: - Conduct regular audits of clinical documentation in the Emergency Medicine department to identify areas for improvement, ensuring accuracy and completeness. - Provide ongoing education to emergency medicine staff on best practices for clinical documentation, including coding guidelines and regulatory compliance. - Work closely with coders, QA staff, leadership, clients, physicians, and clinical staff to clarify documentation issues and promote accurate coding. - Analyze documentation trends to identify opportunities for improvement in clinical practices and documentation accuracy. - Ensure adherence to CMS guidelines and other regulatory requirements related to clinical documentation. - Develop and present reports on documentation improvement initiatives and outcomes to supervisors, stakeholders, and senior leadership. - Participate in initiatives aimed at enhancing patient care and safety in the Emergency Medicine department. - Stay updated with clinical documentation and coding standards through continuing education and professional organizations. Qualifications: - Education: Bachelor's or Masters degree in a life sciences field such as Medicine, Physiotherapy, Occupational Therapy, Physician Assistant, Nursing, Pharmacy, Biomedical Sciences, Biochemistry, Microbiology, or Health Information Management. - Experience: Minimum of 4-5 years of clinical experience in an Emergency Medicine setting, with at least 2 years in clinical documentation improvement or coding. - Certifications: CPC, Certified Clinical Documentation Specialist (CCDS), Certified Documentation Integrity Practitioner (CDIP), or equivalent certification preferred. - Skills: Strong knowledge of medical terminology, anatomy, physiology, coding guidelines (ICD-10, CPT, Modifiers, Category II codes), and clinical documentation standards. Excellent communication, analytical, and problem-solving skills. - Technology Proficiency: Familiarity with electronic health record (EHR) systems and clinical documentation improvement software. (Note: The JD does not contain any additional details of the company),