The Clinical Documentation Integrity Specialist is responsible for utilizing independent clinical judgement in facilitating the integrity, overall quality, accuracy and completeness of provider-based clinical documentation in the medical record. This position is responsible for collaborating with healthcare providers to ensure the documentation in the medical record accurately reflects the severity of illness and risk of mortality of the patient. The CDI Specialist assesses the clinical documentation through extensive reviews of the medical record, interaction with all members of the healthcare team, Quality department and the Health Information Management (HIM) Coding team to ensure appropriate coding and DRG assignment for the level of services rendered to the patient and to ensure that the clinical information utilized in profiling and reporting outcomes is complete and accurate.
- Minimum Associates Degree in health related field or Diploma in nursing required.
- Bachelor’s Degree preferred
- Active Registered Nurse (RN) license or
- Active Registered Health Information Administrator (RHIA) or
- Active Registered Health Information Technician (RHIT) required.
Experience and Knowledge
- Minimum 3-5 year’s clinical and/or ICD-10 coding experience, preferably in a large academic medical center, required.
- Must have thorough, up-to-date clinical skills (i.e. current working knowledge of pathology, pharmacology, surgical procedures, etc.).
- Excellent written and verbal communication skills including presentations required.
- Ability to function independently and as a team player in a fast-paced environment required.
- Must be detail-oriented, and relationship building skills required.
- Demonstrates and has extensive knowledge of disease pathophysiology
Skills and Knowledge
- Demonstrated ability to use PCs, Microsoft Office suite, and general office equipment (i.e., printers, copy machine, FAX machine, etc.) required.
- Experience using clinical computer systems required.
Location/Region: Elyria, OH (44035)