Clinical Documentation Improvement Specialist (CDI) in Norwalk, CA at Avanti Hospitals

Date Posted: 7/29/2019

Job Snapshot

Job Description

Coast Plaza Hospital

Job Title: Clinical Documentation Improvement Specialist (CDI) 

City: Norwalk / State: California    

CDI

Day Shift

From 7:00 AM

To 3:30 PM

                                      


Job Description and Job Responsibilites

Job Title:  Clinical Documentation Improvement Specialist (CDS)

Job Summary:

Responsible for reviewing medical records to facilitate the accurate representation of the severity of illness.  This position facilitates improvement of clinical documentation in the medical record to ensure an accurate level of clinical services, appropriate coding of principal and secondary diagnose, complications and POA indicators that drive reimbursement, quality performance metrics, and CMI. The position reports to the Lead CDI Specialist.  

 

Essential Job Duties: 

  • Obtains and promotes appropriate clinical documentation.
  • Interacts with physicians, clinical staff and health information management professionals.
  • Reviews medical records and identifies potential gaps in clinical documentation for specified patient types and payer population.
  • Completes concurrent review of assigned population.
  • Works with coding staff to assure documentation of discharge diagnoses and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care.
  • Submit queries to medical staff and follow-up on queries.
  • Input coding information into the system for population into the daily census.
  • Serves as a role model for the Mission, Vision and Values of the organization and fulfills their job duties as requested within Scope of Practice
  • Maintains current competencies as well as updated knowledge in specific area of practice

Behavioral Standards: 

  • Exhibits customer and service oriented behaviors in every day work interactions.
  • Demonstrates a courteous and respectful attitude to internal workforce and external customers.

Communication/Knowledge:

  • Provides accurate and timely written and verbal communication of clinical information in a manner that is understood by all involved in the delivery of patient care.
  • Able to listen, understand, problem-solve, and carry-out duties to ensure the optimal patient care outcomes.
  • Able to use IT systems in an accurate and proficient manner.

Collaboration/Teamwork:

  • Contributes toward effective, positive working relationships with internal and external colleagues.
  • Demonstrates cooperation, flexibility, reliability, and dependability in all daily work activities and a willingness to collaborate with others for the good of the customer and the organization. 




Job Requirements

Education/Experience:

  • Degree required.  RN or MD degree a strong plus.
  • Minimum of 2 years in acute setting with at least 6 months experience in performing clinical documentation improvement (“CDI”) functions

Licensure/Certifications:

  • CDIP/CCDS is preferred
  • ICD-10 certification is preferred
  • CCS certification is strongly preferred.

ADA/Physical Demands:

  • To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed are representative of the knowledge, skill, and/or ability required.  Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Such accommodations must be requested by the employee/applicant in order to be considered.
  • Required to stand; walk; sit; use hands to fingers, handle, or feel; reach with hands and arms; stoop, kneel, crouch, or crawl; talk and hear; and may taste and smell.  The employee is regularly required to lift, push and/or pull weights in excess of 10 pounds, with assistance. Visual abilities, auditory abilities, must be intact to perform duties.

 

Job Requirements

Education/Experience:

  • Degree required.  RN or MD degree a strong plus.
  • Minimum of 2 years in acute setting with at least 6 months experience in performing clinical documentation improvement (“CDI”) functions

Licensure/Certifications:

  • CDIP/CCDS is preferred
  • ICD-10 certification is preferred
  • CCS certification is strongly preferred.

ADA/Physical Demands:

  • To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed are representative of the knowledge, skill, and/or ability required.  Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Such accommodations must be requested by the employee/applicant in order to be considered.
  • Required to stand; walk; sit; use hands to fingers, handle, or feel; reach with hands and arms; stoop, kneel, crouch, or crawl; talk and hear; and may taste and smell.  The employee is regularly required to lift, push and/or pull weights in excess of 10 pounds, with assistance. Visual abilities, auditory abilities, must be intact to perform duties.