Summary: The CDI Specialist is responsible for improving the overall quality and completeness of our clinical documentation. The CDI Specialist is responsible for interacting with physicians and other patient care providers and coders in establishing the principal and secondary diagnoses, principal and secondary procedures concurrently to promote appropriate DRG, APC, and ER Leveling assignments. Responsible for identifying and assisting the Director in resolving problems related to documentation issues and assisting in provider documentation training. Responsible for appealing any insurance denial or DRG downgrade based on documentation and coding issues.  Responsible to detect, observe, and report compliance variances to the Director of the HIM Department or upward through the chain of command, the Compliance Officer or Hospital hotline.  

Duties: 

•    Concurrently reviews patient chart documentation during hospital admission to ensure complete and accurate patient records, including the use of Present on Admission indicators.
•    Obtains documentation relevant to denials avoidance related to the Recovery Audit program, the Comprehensive Error Rate Testing (CERT) program, and other audit programs, recognizing and disseminating to physicians the importance of clinical documentation for both the physician and the hospital. 
•    Reviews medical necessity denials and provides constructive feedback to providers. 
•    Works with all physician specialties in clinical documentation improvement initiatives, effectively tailoring learning and education opportunities to each physician specialty on an "as you go" basis.
•    Collaborates with case managers to capture patient severity of illness and intensity of service to ensure medical necessity. 
•    Collaborates with Coding Team to ensure proper documentation. 
•    Registers and attends all relevant ICD-10 and other billing/coding related educational offerings by CMS contractors, effectively sharing with physicians on a need to know basis, integrating key concepts and elements as they relate to clinical documentation improvement into daily routines and practices of CDI.

Required: Graduate from a Board approved nursing program with current licensure as a registered nurse in the state of North Carolina required;  Familiarity with MS-DRGs and the Inpatient Prospective Payment System (IPPS), including new CMS guideline of key elements including clinical documentation of what constitutes an inpatient admission.Practical knowledge and understanding of official physician E & M guidelines and documentation requirements in support of proper E & M assignment and establishment of medical necessity. Effective ability and willingness to communicate benefits of complete and accurate documentation to physicians relating to their daily practice of medicine. 

Preferred: BSN preferred. CCDS and/or CCS preferred or 3 years relevent clinical experience in CDI preferred.  Working knowledge of meditech and 3M encoding software preferred.