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CDI Outpatient PRN
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- The Clinical Documentation Integrity Specialist (CDI) is a clinical position using clinical/nursing knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation within the patient electronic medical record using multidisciplinary team process.
- Conducts initial concurrent review and ongoing re-review for all selected admissions to initiate the tracking process, document findings on the CDS worksheets, and identify other key pathway or quality indicators as appropriate.
- Utilizes clinical knowledge to identify need to clarify documentation in records, and utilizes strong commination skills with physician, physician extender, case manager, utilization review, nurse or other healthcare professionals, utilizing appropriate tools to capture needed documentation.
- Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment.
- Reviews coder feedback on completed worksheets and individual CDS tracking system reports as a means of continuous self-evaluation; discusses any issues or concerns with the CDI Supervisor.
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