Job Summary:

Under the direction of the Clinical Documentation Coordinator/Supervisor, this position is responsible for performing concurrent coding and medical record chart review on open records. Ensures appropriate interim MS-DRG/APR-DRG (All Patient Refined Diagnosis Related Group) SOI (Severity of Illness) and ROM (Risk of Mortality) for given patient assignments. Completes physician query forms and collaborates with physicians and physician advisors to obtain accurate, timely physician documentation in patient medical records. Works with HIM Coding staff in preparing charts for final coding. The CDI specialist must have a good working relationship with all physicians. He/she must be able to provide educational opportunities and be able to accurately answer physician questions when rounding at the hospital.

Performance Expectations:

• Demonstrates ability to complete 285 concurrent chart reviews per month.
• Demonstrates ability to submit 20 compliant coding queries per month. CDI specialist will maintain a 75-80% minimum review rate for non-complex cases and a 12-14% review rate for complex cases.
• Demonstrates ability to interact with providers.
• Demonstrates ability to work effectively with the coding staff regarding outstanding coding queries and/or documentation issues.

Qualifications:

Education/Skills

Bachelor of Science Degree, or Associates degree in nursing (preferred) or Associate Degree in Health Information Management, or 10+ years of experience coding inpatient records at a large (400+bed) acute care facility.

Work Experience:

Two years of experience in Coding inpatient medical records at a large acute care facility, two years of clinical nursing experience or two years of experience in Case Management/Utilization Review are preferred. Familiarity with computerized record systems required.

Certification/Licensure-DUE UPON HIRE

• Licensed RN able to practice within the State of MS

OR

• RHIA, RHIT, CCS, CCS-P, CCA, CPC, COC, CPC-A or CIC required.

Mental Demands:

Must be detail oriented and able to work independently. Ability to work collaboratively with multiple professional staff and physicians to improve clinical documentation. Excellent verbal and written skills are a must. Must be able organize and prioritize tasks and function in a fast paced environment.