Senior Clinical Documentation Improvement

Department: Revenue Cycle Management/Clinical Documentation Improvement

Reports To: CDI Manager/Director

Summary:

The Senior CDI Specialist is responsible for leading clinical documentation improvement efforts to ensure accurate and complete medical record documentation that supports appropriate coding, reimbursement, and quality reporting. This role requires expertise in clinical documentation requirements, coding guidelines, and regulatory standards. The Senior CDI Specialist performs comprehensive medical record reviews, collaborates with physicians and other healthcare providers, provides education and training, and serves as a resource for the CDI team.

Key Responsibilities:

Medical Record Review:

• Conduct concurrent and retrospective reviews of inpatient and outpatient medical records to identify opportunities for documentation improvement.
• Evaluate the accuracy and completeness of clinical documentation to ensure it reflects the patient's condition, treatment, and outcomes.
• Identify discrepancies, inconsistencies, and missing information in the medical record.
• Analyze documentation to determine the principal diagnosis, comorbidities, and complications.

Physician Collaboration and Education:

• Communicate with physicians and other healthcare providers to clarify documentation and obtain additional information.
• Provide education and training to physicians and other healthcare providers on documentation requirements, coding guidelines, and regulatory standards.
• Conduct one-on-one education sessions with physicians to address specific documentation deficiencies.
• Develop and deliver educational materials, presentations, and workshops on CDI topics.

Coding and Reimbursement:

• Ensure that documentation supports accurate coding and billing practices.
• Collaborate with coding staff to resolve coding discrepancies and documentation issues.
• Understand the impact of documentation on reimbursement and DRG (Diagnosis Related Group) assignment.
• Stay current on changes in coding guidelines (ICD-10, CPT, HCPCS) and reimbursement policies.

Data Analysis and Reporting:

• Collect and analyze data related to CDI activities, including query rates, physician response rates, and documentation improvement metrics.
• Prepare reports and presentations on CDI performance and trends. Identify opportunities to improve CDI processes and outcomes.
• Participate in quality improvement initiatives and performance improvement projects.

Regulatory Compliance:

• Ensure compliance with all applicable regulatory requirements, including HIPAA, CMS (Centers for Medicare & Medicaid Services), and Joint Commission standards.
• Stay current on changes in regulatory requirements and guidelines related to clinical documentation and coding.
• Participate in internal audits and external reviews of clinical documentation.

Team Leadership and Mentorship:

• Serve as a mentor and resource for junior CDI Specialists.
• Provide guidance and support to the CDI team on complex cases and documentation challenges.
• Assist in training new team members on CDI processes and procedures.
• Participate in team meetings and contribute to the development of CDI strategies.

System Proficiency:

• Utilize electronic health record (EHR) systems and CDI software to manage medical record reviews and documentation queries.
• Maintain accurate and up-to-date information in CDI tracking systems.

Qualifications, Experience & Skills:

• Registered Nurse (RN), Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS), or other relevant clinical or coding certification required.
• Bachelors degree in science, Pharma, Nursing, Health Information Management, or a related field preferred.
• Minimum of 5-7 years of experience in clinical documentation improvement, coding, or related healthcare field.
• Strong knowledge of medical terminology, anatomy and physiology, and disease processes.
• Experience working with electronic health record (EHR) systems.
• Excellent communication and interpersonal skills.
• Strong analytical and problem-solving abilities.
• Ability to work independently and as part of a team.
• Excellent organizational and time-management skills.
• Proficiency in using Microsoft Office Suite.

Certifications:

• Required: RN, CCS, CCDS, or other relevant clinical or coding certification.
• Experience with EPIC preferred but not mandatory
• Both Hospital and Professional CDI experience preferred
• Flexible to work from Office all 5 days in the week
• IP CDI (min 2 to 3 Years experience) with AAPC/Ahima Certification. Registered nurse qualification is preferred, not mandatory. Registered Nurse (RN), Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS), or other relevant clinical or coding certification required.