Clinical Documentation (CDI) Specialist

We are Vista Hospital. Our primary function is to offer continuous nursing, medical, and other health and social services on a 24-hour basis, under physician directed care and RN supervision.

We service a multitude of patients and their families across our vast network, while remaining committed to the professional development of our staff, the functional improvement of our patients, and the cultivation of strong partnerships within our communities.

WHAT WE OFFER

Essential/stable and growing company with many opportunities for training and advancement within the medical field that all employees and team members (including Full-Time and Part-Time) can benefit from.
Hourly pay is negotiable based on experience. We offer competitive market pay and opportunities for bonus depending on great work performance (bonuses only apply for Full Time).
Comprehensive Employee Benefits: Full-Time employees are eligible for various plans for medical, dental, and vision insurance.

The clinical documentation specialist collaborates extensively with physicians, nursing staff, other patient caregivers and coding staff to improve the quality and completeness of documentation of care provided and coded for coordination, abstraction and submission of accurate data required by CMS. Facilitates concurrent modifications to clinical documentation to insure commensurate reimbursement of clinical severity and services rendered to patients with a Diagnosis Related Group based payer (Medicare, Medicaid). Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. Communicates with and educates all physician and clinical staff concerning accurate and effective clinical documentation.

PRIMARY RESPONSIBILITIES

Build and generate reports from the EMR.
Review concurrent medical record for compliance including completeness and accuracy for severity of illness (SOI) and quality.
Complete accurate and timely record review to ensure the integrity of documentation compliance.Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision making keeping reimbursement considerations in balance with regulatory compliance.
Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including attending physicians, allied health practitioners, nursing, and care management. This includes quarterly compliance updates from Medicare.
Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation. Communicates with HIM staff and collaborates with them to resolves discrepancies with DRG assignments and other coding issues.
Complete well-timed follow-up case reviews on all concurrent cases with priority given for resolution of those with clinical documentation clarifications.
Participate in meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified.
Other duties as may be assigned.

EDUCATION/EXPERIENCE

Bachelor's Degree in Health Information Management Required,
Clinical Background and or prior experience within CDI, Certified Coder Documentation Specialist