Job Description

Serves as the primary resource to the treatment team on all aspects of medical record documentation required to support the accurate classification of patient's severity of illness/medical complexity. Possess extensive knowledge of both clinical medicine and disease management, as well as the internal and external patient classification systems that measure patient's severity of illness and medical complexity. Additionally, the CDI specialist will be the primary educator for the implementation of the International Classification of Disease Classification System, 10th revision. The CDI specialist shall be responsible for clarifying documentation regarding quality of care issues. Responsible for the daily review of current inpatient medical records, abstracts pertinent clinical information and translates the clinical information into a hospital based coding system utilizing ICD-10. Identifies opportunities for documentation improvement to support accurate assignment of diagnostic related groups (DRGs), severity of illness (SOI) assignment, risk of mortality (ROM) assignment, and correct reporting of quality metrics. Communicates with the clinical staff through a variety of means to educate the staff and obtain clarification of documentation.



Education

Bachelor's Degree in a related field or an Associate's degree in a healthcare related field

with 5 years of related experience Required or

Combination of relevant education and experience may be considered in lieu of degree Required



Experience

2 years experience in Patient care or Coding (inpatient medical setting) Required

5 years experience in inpatient acute care Preferred



Licenses

Certified Coding Specialist Preferred or

PA Practical Nurse License Preferred or

PA Registered Nurse License Preferred