Clinical Documentation Integrity; CDI Specialist - Remote

What You Will Do

The Clinical Documentation Integrity Specialist reviews and analyzes health records to identify opportunities to clarify relevant diagnoses and procedures for distinct patient encounters. Works collaboratively with providers, other health care professionals and coding team to ensure that clinical information in the medical record is present and accurate so that the appropriate utilization, clinical severity, outcomes, and quality is captured for the level of service rendered to each patient, as well as ensuring compliant reimbursement of patient care services.

• Conducts comprehensive initial and follow-up concurrent reviews of medical records for assigned patients in the time frame, frequency and prioritization as defined for the CDI team
• Identifies opportunities to clarify incomplete or conflicting documentation and/or to validate diagnosis in the medical record.
• Understands the guiding principles of clinical validation and writing a compliant query
• Prepares a compliant written query for responsible treating physician, following the most current ACDIS/AHMIA Guidelines to Achieving a Compliant Query Process
• Identifies principal diagnosis options, secondary diagnoses and significant procedures in order to assign working MS-DRG.
• Establishes a working DRG and updates DRG based on record documentation during concurrent reviews to reflect current expected Length of Stay as appropriate
• Utilizes the appropriate UAB query template and follows 2022 ACDIS/AHIMA Guidelines to Achieving a Compliant Query Process
• Ensures relevant and/or approved clinical indicators specific to the patient and the clinical record are cited on the query template.
• Choices provided on the query must reflect reasonable conclusions specific to the patient and the clinical record
• Demonstrates knowledge of Patient Safety Indicator’s (PSI’s), Hospital Acquired Conditions (HAC’s), Severity of Illness & Risk of Mortality (SOI/ROM) as well as present on admission status
• Ability to appropriately apply and use hospital approved clinical indicators for specified diagnoses
• Ability to follow hospital specific procedures and policies with regards to documentation requirements, query escalation, DRG reconciliation and other duties.
• Tracks physician query response documented in the medical record
• Maintains productivity and established performance benchmarks for quality
• Ensures competency in use of CDI application to process and prioritize daily work lists, capture results of record reviews, track queries and query responses.
• Enters all required data into CDI application and/or other systems to enable coders and CDI/Coding auditors to determine disposition of concurrent queries in order to assign the final MS-DRG as well as SOI and ROM
• Ensures competency in use of electronic coding references to code and assign working MS-DRG along with, SOI and ROM; as well as reference related Official Coding Guidelines and Coding Clinic for accurate code assignment
• Collaborates with Coding team on any questions related to ICD-10 coding and/or MS-DRG assignment, involved in the preparation of concurrent and/or retrospective queries.
• Participates in DRG reconciliation process in a collaborative, timely, and thorough manner with coders
• Participates in departmental and hospital committees, assigned task forces, including service line assignment meetings as requested
• Contributes to a positive and collaborative working environment
• Comply with HIPAA and code of conduct policies

• Graduation from accredited School of Nursing
• Bachelor’s degree in health-related field and/or Masters required with a current/active license OR Graduation from accredited medical school with MD OR RHIA, RHIT or CCS Certification with a current/active license
• At least one of the following: RN, MD or MD Equivalent, RHIA, RHIT, CCS, with a current/active license
• 2-4 years acute care inpatient hospital coding or CDI experience
• Familiarity with encoder and DRG assignment
• Maintain current working knowledge of official coding guidelines and coding clinics

• CCDS, CDIP preferred.
• Strong clinical understanding of disease process.
• Demonstrate…