Position Summary

Clinical Documentation Improvement Specialist performs concurrent review of Provider documentation of designated Inpatient records as part of the DRG Assurance Program.  Duties include written/verbal  communication to providers via compliant queries that seek clarification of inconsistent or ambiguous documentation to accurately code and assign MS DRGs and APR DRG in order to  ensure our data is captured for statistical as well as billing purposes. CDIS assist providers to document conditions/diseases that they are treating in such language that is recognized by the coding community and reflects the severity of illness and risk of mortality.    

Minimum Requirements

Education           

RN or RHIT/CCS  with extensive coding/clinical knowledge

Experience        

If RN, Acute Care Hospital Nursing 5+ yrs. Acute care Hospital IP coding experience 5+ yrs.   

License/Registration/Certifications       

CCDS or CDIP

Preferred Requirements

Preferred Education      

BSN, RHIA/CCS

Preferred Experience   

5+  Years of experience at tertiary teaching acute care hospital in IP and CDI

Preferred License/Registration/Certifications   

BSN, RHIA, CCDS or CDIP

Core Job Responsibilities

Thoroughly reviews provider documentation and concurrently assigns ICD 10, ICD 10 PCS , APR DRG and MS DRGS using the 3M 360 Encoder Software. Constructs verbal / written compliant queries to provides to ensure  patients documentation and  coding is accurate Thorough knowledge of APR DRG &  MS DRGs Ensures accurate SOI, ROM Answers clinical questions that IP coders may have on charts being coding Teamwork and being a highly engaged associate Achieves all the above while maintaining established productivity and accuracy goals Other duties as assigned