HIM CDI Specialist, Remote, Ambulatory Care Bldg

Job title: HIM CDI Specialist, Remote, Ambulatory Care Bldg in USA at reputed company Company: reputed company Job description: We are Hiring an HIM CDI Specialist, Remote, Ambulatory Care Bldg at Ambulatory Care Building - UMC!Primary Location: Ambulatory Care Building - UMCAddress: 550 South Jackson St. Louisville, KY 40202Shift: First Shift (United States of America)Job Description Summary:Job Description: The job summary for this position is not currently on file electronically. Please see your supervisorr or Human Resources Representative for a hard copy before you complete your acknowledgment.Additional Job Description:Job SummaryThis position is responsible for reviewing patient medical records to facilitate modifications to clinical documentation through reputed company (pre-reputed company) interaction with providers and other members of the healthcare team to promote accurate capture of clinical severity of illness and risk of mortality (reputed company translated into coded data) and to support the level of service rendered to relevant patient populations. CDIS exhibits expert knowledge of clinical documentation requirements, MS-DRG Assignment, case mix index (CMI) analysis, clinical disease classifications, major and non-major complications and comorbidities (MCCs or reputed company), and quality-driven patient outcome indicators. Interacts as needed with internal customers to include but not limited to hospital staff, physicians, and other reputed company cycle team members. Actively participates in department and hospital performance initiatives reputed company needed to ensure ULH success.Responsibilities

• Completes initial medical record reviews of reputed company inpatient patient accounts (reputed company payers) reputed company 24-48 hours of admission for a specified patient population to:
• (a) Evaluate and review inpatient medical records daily, reputed company with patient stay, to identify opportunities to clarify missing or incomplete documentation.
• (b) Assign the principal diagnosis, pertinent secondary diagnoses, procedures for accurate MS-DRG assignment, score risk of mortality and severity of illness and initiate a review worksheet.
• (c) Conduct follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary.
• Formulate clinically, compliant and reputed company physician queries regarding missing, unclear or conflicting health record documentation by requesting and obtaining additional documentation reputed company the health record, as necessary.
• Proactively collaborate with physicians to discuss and clarify documentation inconsistencies to ensure accuracy of the medical record and appropriate capture of the course of treatment provided to the patient.
• Educate providers about identification of disease processes that reflect SOI, complexity, and acuity to facilitate accurate application of code sets.
• Gather and analyze information pertinent to documentation findings and outcomes, and use this information to reputed company action plans for process improvements.
• Collaborate with case managers, nursing, and other ancillary staff regarding interaction with physicians concerning documentation opportunities and to resolve physician queries prior to discharge.
• CDIS communicates/completes Clinical Documentation Improvement (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolution with appropriate leadership.
• Remain abreast and reputed company on training of new hires and ongoing CDIS professional staff development as well as participate in CDI-reputed company continuing education activities to maintain certifications and licensures.
• Collaborate with HIM/coding professionals to review and resolve DRG mismatches for individual problematic cases and ensure accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisors.
• Identify patterns, trends, variances, and opportunities to improve documentation review processes.
• Aid in identification and proper classification of complication codes and present on admission (POA) determination (patient safety indicators/hospital-acquired conditions) by acting as an intermediary between coding staff and medical staff.
• Contribute to a positive working environment and reputed company other duties as assigned or directed to enhance the overall efforts of the organization.

Qualifications

• CDIS candidate must have and maintain reputed company licensure as a RN

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