Clinical Documentation Integrity Specialist

Job Title: Clinical Documentation Integrity Specialist Location: Hybrid at Escondido, CA Duration: 6 month Contract to hirePosition Summary The CDI Specialist is responsible for comprehensive Initial and secondary clinical chart reviews to identify potential missed opportunities for documentation clarification. In this role, you will collaborate closely with Coders, Coding Educators, Coding Quality Auditors, Case managers, Quality Department and Providers to assure documentation is clinically appropriate, accurately reflects the severity of illness and risk of mortality for the patient and is reflective of current CMS or other regulatory standards. Conducts daily, concurrent review of inpatient records on assigned unit(s) to ensure complete and accurate physician and or clinician documentation is present at the time of discharge for accurate, timely, and compliant coding.Reviews daily admissions to assigned unit, perform initial code assignment for a working DRG and complete CDI software data entry for initial and follows up case reviews (or worksheet to include code and DRG assignment) and submit to Program Assistant.Updates “working DRG” as documentation supports, or physician query answer supports a change in the DRG assignment.Communicates to the CDI Coordinator when volume of daily review assignments is too high or low so that CDI Coordinator can assist in adjusting review assignments amongst the team.Initiates compliant physician queries when documentation is confusing, ambiguous, or missing and follows up with MD to seek immediate response to query (utilizing the following AHIMA practice briefs as a guide: “Managing an Effective Query Process,” October 2008 and “Guidance for Clinical Documentation Improvement Programs”, May 2010).Ability to assess and identify potential health system opportunities in regards to contractual and best practice CDI metricsAssist in the development of processes and initiatives designed to improve clinical documentation performanceDemonstrate effective communication skills and collaborate with medical staff, clinical departments and key facility leadership team members as neededMaintains and demonstrates strong knowledge of CDI and coding process best practicesResponsible for daily onsite CDI program to include productivity, quality, education and training, auditing, report management, performance improvement initiatives and developing standardized practices, processes and policies and procedures.Become an advocate for facilitating the best practice model for CDI, linking the most accurate capture of documented bedside care to the most accurate numeric reporting codes thereby, conversion into correct reporting, facility and physician profiling and acuity capture.Build trustworthy and strong relationships with client staff, physician base and other Guidehouse team members What You Will Need:Bachelor's degreeOne of the following: RN, MD, or MD Equivalent (MBBS)5 years acute care inpatient hospital CDI experienceFamiliarity with encoder and DRG assignmentMaintain current working knowledge of official coding guidelines and coding clinics What Would Be Nice to Have:CCDS, CDIP preferredStrong clinical understanding of disease processDemonstrate critical thinking, analytical skills, and ability to resolve problems.Strong knowledge of medical terminology, anatomy, physiology, microbiology, and disease processesAbility to converse with physicians in sometimes difficult scenariosStrong typing and computer skills; proficiency with EHR systems, CDI software systems and encoders