CDI Lead Specialist - Saint Joseph Hospital East

Job Summary

Educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management. Assist with overseeing department workflow and metrics. Create reports used to make strategic decisions. Educate and train department staff. Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians’ clinical documentation.

Include the following. Others may be assigned.

• Completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness; and (b) initiate a review worksheet.
• Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary.
• Formulate physician queries regarding missing, unclear or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary.
• Collaborates with case managers, nursing staff and other ancillary staff regarding interaction with physicians regarding documentation and to resolve physician queries prior to discharge.

• Provides daily support/mentoring/training to new hires as well as existing staff.
• Provides assistance in managing escalated issues and special projects as needed to supervisors and managers. CDI staff coverage
• Performs concurrent and retrospective CDI audits
• Provides CDI support/mentoring/training to Physicians and hospital leadership as needed.
• Completion of scrubbing and submitting monthly data to vendor
• Enters facility specific data to dashboards
• Resolves problems, concerns and reports issues with Operations Supervisor, Manager or Director.

• Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-9-CM and CPT coding.
• Attends mandatory coding seminars on annual basis (IPPS and OPPS, ICD-9-CM and CPT updates) for inpatient and outpatient coding.
• Quarterly review of AHA Coding Clinic.
• Attends Quarterly Coding Updates and all coding conference calls as well as any required CDI education.

• Communicates/Completes Clinical Documentation Improvement (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolution

• Preferred:
  Three (3) or more years experience in CDI
• Graduate from a Nursing program, BSN, or graduate of Health Information Management RHIT, RHIA preferred
• Preferred:
  Two (2) years experience with either HIM/Coding or Case Management experience.

• Required:
  
  RN, or RHIT, RHIA, and/or CCS
• Preferred: CDIP or CCDS

• Ability to sit for extended periods of time
• Must be able to efficiently use computer keyboard & mouse to perform CDI functions
• Good visual acuity

• Must be able to travel regionally as needed, not to exceed 10%

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare.

Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

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