Clinical Documentation Integrity (CDI) Specialist

Perform concurrent and retrospective chart reviews to improve completeness of clinical documentation. Keep abreast of current coding trends and maintain up-to-date knowledge of Medicare rules regarding diagnosis coding and CDI trends. Effectively utilize ICD-10 and related materials to investigate coding issues. Conduct daily follow-up communication with providers to obtain needed documentation specificity. Provide expert-level leadership for overall improvement in clinical documentation by providing proficient review and assessment, and articulating recommendations for improvement. Actively communicate with providers at all levels to clarify information and communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality. Ensure effective utilization of technology to document all clarification activity. Collaborate closely with interfacing departments such as Care Coordination and Quality. Proactively develop reciprocal relationship with HIM Coding Professionals. Engage and consult with Physician Advisor/CMO when needed per hospital defined escalation process.