Clinical Documentation Improvement (CDI) Specialist - H.I.M.
Under supervision by the Clinical Documentation Improvement (CDI) Manager, the CDI Specialist is responsible for coordinating and performing the day-to-day operations and workflow of the CDI program. These include providing concurrent documentation reviews, DRG and coding reviews for Inpatient Acute Care, Outpatient Clinic, Outpatient Surgery, Emergency Department, Observations (OBS), etc. that ensure high quality documentation which supports a compliant and accurate representation of the care provided to the patient. All work is carried out in accordance with the rules, regulations and coding conventions of the American Hospital Association (Coding Clinic), ICD-10 CM/PCS, ICD-9-CM, CDI, Centers for Medicare and Medicaid Services (CMS), Office of Statewide Health Planning and Development (OSHPD), and other accepted organizational/institutional coding guidelines. Responsible and accountable for assisting the CDI Manager with the daily review and completion of documents, reports, and quality monitors as they relate to the CDI program.
Bachelor's Degree in the Health Care field (e.g. nursing) or other field that is closely related to Health Information Management.
Master's Degree preferred.
RHIA, RHIT,k RN or CDI, CDIP or CCDS credentials required (non-credentialed employee on hire must obtain required credentials within one-year from date of hire).
Completed course work in medical record technology, anatomy, or physiology required.
Equivalent combinations of one year of education equals one year of experience.
Previous technical experience required through knowledge of federal and state documentation guidelines.
Two (2) to three (3) years' experience as a hospital CDI Specialist.
Requires knowledge of third party payor's, APC and DRG assignments.
Must be knowledgeable about coding guidelines, as they pertain to inpatient, outpatient, and ambulatory care, and familiarity with coding references.
3M encoder experience.
Excellent computer skills
Knowledgeable of medical record requirements and the ability to analyze documentation and assign the proper code.
Ability to follow written and oral instructions and established procedures,and proficiency in data entry/10-key.
Licensure & Certifications
CDI, CDIP or CCDS Certification required at time of hire or within one-year from date of hire. Additional Information Position Type : Full Time Shift : Day Contact Information
Janice Lincoln - HR Specialist/Recruiter
Rehoboth McKinley Christian Health Care Services
1901 Red Rock Drive
Gallup, NM 87301