Clinical Documentation Integrity (CDI) Specialist

Job not on LinkedIn

🔥 0 minutes ago

🏈 Ohio – Remote

🏈 Ohio – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🏥📝 Medical Writer

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University Hospitals

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

📚 Education

💰 $2M Grant on 2021-07

Healthcare • Medical Services • Education

University Hospitals is a leading healthcare provider that offers a wide range of medical services, including primary care, specialty care, and urgent care. With a focus on patient-centered care, UH also engages in medical education and research, ensuring high-quality treatment and innovative healthcare solutions. The institution is recognized nationally for its excellence in various medical specialties, providing accessible healthcare to the community and beyond.

📋 Description

• Review medical records to ensure documentation accuracy, completeness, integrity, and appropriate code/working DRG assignment • Use clinical and/or coding expertise to identify documentation clarification opportunities reflecting patient complexity, resource utilization, severity of illness, and risk of mortality • Follow up directly and promptly with clinical providers for requested clarification • Write AHIMA-compliant queries and escalate physician non-response according to policy • Collaborate with coding teams, clinical departments, medical staff, finance, CDM, and other healthcare team members • Educate physicians and clinical care providers through rounding, service-line sessions, and one-to-one case feedback • Support accurate reporting of quality outcomes, billing, public reporting, research data, quality metrics, provider scorecards, UHDDS, and Case Mix Index • Meet productivity, quality, ethical, operational, and departmental standards • Use the CDI business platform proficiently and efficiently • Cross-cover units, specialties, and hospitals as assigned • Mentor other Clinical Documentation Specialists and participate in committees • For outpatient work, research missed charges, coordinate claim corrections, analyze clinical and billing data, prepare summaries, maintain project plans and tracking, and monitor defined areas • Perform other assigned duties and comply with policies and PHI requirements

🎯 Requirements

• Associate's Degree in health related field (Required) or Diploma in RN (Required) • Bachelor's Degree in health related field (Preferred) • 2+ years in CDI Specialist role (Required) • 3+ years clinical and/or ICD-10 coding experience, preferably in a large academic medical center (Required) • Experience using clinical computer systems (Required) • Thorough, up-to-date clinical skills, including pathology, pharmacology, and surgical procedures • Excellent written and verbal communication skills, including presentations • Ability to function independently and as a team player in a fast-paced environment • Detail-oriented and relationship-building skills • Extensive knowledge of disease pathophysiology • Ability to use PCs, Microsoft Office suite, and general office equipment • Registered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire), or RHIA (Required), or RHIT (Required) and CCDS (Required) or CDIP (Required) • Must safely and securely maintain Protected Health Information (PHI) • Physical ability to meet listed demands, including occasional standing/walking, constant sitting/talking/hearing, and lifting/carrying/pushing/pulling up to 20 lbs rarely • Travel requirements listed as 10%

🏖️ Benefits

• Remote work • Full-time regular employee status • Annual training • UH Code of Conduct and workplace policies addressing appropriate use of PHI