Inpatient Clinical Documentation Integrity (CDI) Specialist

Inpatient Clinical Documentation Integrity:

About the Role:

Key Responsibilities

Clinical Documentation and Coding Accuracy:

· Conduct comprehensive reviews of inpatient medical records to validate clinical documentation and ensure ICD-10-CM/PCS coding accuracy.

· Collaborate with providers to ensure documentation supports accurate DRG assignments, SOI, ROM, as well as CCs and MCCs.

· Address documentation gaps, inconsistencies, and areas requiring clarification through focused queries.

· Analyze coding data to identify discrepancies, trends, and areas for improvement.

· Ensure diagnoses critical for mortality and other risk models are documented as "POA.”

Subject Matter Expertise:

· Serve as a key resource for inpatient coding, DRG assignments, and SOI assessments.

· Work closely with coding teams to resolve discrepancies and enhance coding accuracy.

Collaboration and Education:

· Build strong partnerships with physicians, CDI specialists, and clinical teams to bridge documentation gaps.

· Provide targeted education and training on documentation standards, compliance, and best practices.

· Facilitate training sessions to enhance understanding of CDI processes and their impact on quality metrics and reimbursement.

· Function as a liaison between clinical teams, coders, and revenue cycle management.

Compliance and Auditing:

· Ensure all documentation adheres to regulatory standards, including CMS, Joint Commission, and other compliance requirements.

· Participate in audits, evaluate findings, and recommend corrective actions, as needed.

· Support organizational quality initiatives and contribute to performance improvement projects.

Qualifications and Skills

Required Credentials and Experience

· Certifications:

· Experience:

· Advanced knowledge of US healthcare reimbursement methodologies, including MS-DRG and APR-DRG.

· Familiarity with payer-specific policies, official coding guidelines, and regulatory standards (e.g., CMS, AHIMA).

· Proficiency in EHR systems (e.g., Epic, Oracle-Cerner) and coding tools (e.g., 3M, Nuance, Optum).

Desired Skills:

· Exceptional analytical skills to identify trends and resolve discrepancies in documentation and coding.

· Outstanding interpersonal and communication abilities to foster collaboration and provide education.

· Proven track record of delivering effective training sessions and analyzing CDI metrics such as query response rates and documentation improvements.

· Up-to-date knowledge of regulatory changes and industry best practices in CDI.

Why Join Us?

Take the Next Step in Your CDI Career: