About This Role
This role, also known as a CDI Coordinator, supports clinical documentation initiatives for a hospital or health system. It involves assisting with program support, special projects, process implementation, and continuous process improvement, focusing on reviewing medical records to ensure clear physician documentation for accurate coding. The specialist also serves as a resource for Clinical Documentation Specialists, physicians, and leaders.
Responsibilities
- Perform concurrent and/or retrospective CDI review of acute inpatient medical records for clarity and specificity of physician documentation
- Place queries for physicians in the medical record, requesting clarification of the principal diagnosis or secondary conditions of the patient
- Serve as a CDI resource to physicians, CDI staff, coders, and other stakeholders regarding documentation improvement initiatives, CDI workflows, and documentation best practices
- Perform CDI audits to identify trends or problem areas for documentation and coding
- Collect, analyze, and/or prepare CDI metrics, documentation trends, and other designated program measures to support process improvement initiatives
- Assist with monitoring and tracking CDI processes and related outcomes
- Operate within the compliance guidelines of Medicare and Medicaid Services
- Always consider compliance and display ethical decision-making skills
- Know, understand, and comply with applicable federal and state laws, Corporate Compliance policies and procedures, reporting requirements, accrediting body standards, and organizational compliance expectations
- Work collaboratively with CDI leadership, CDI staff, coding professionals, physicians, and other stakeholders to support documentation improvement initiatives and program goals
- Work collaboratively with departments, vendors, and external partners on CDI initiatives, special projects, and process improvement activities supporting documentation integrity and organizational objectives, as directed by CDI leadership
- Function as a CDI team resource
- Assist with problem solving and CDI initiatives including process improvements and the implementation and support of new processes
- Serve as a liaison between CDI operations, coding, information systems, vendors, and organizational stakeholders to support CDI technology, workflows, and processes, as directed by CDI leadership
- Assist with the design, development, implementation, and testing of workflows, tipsheets, educational materials, query templates, CDI reference tools, and special project content supporting the CDI program
- Assist CDI leadership with development and maintenance of reports, audits, dashboards, tracking tools, and educational resources used to monitor CDI program performance
- Assist CDI leadership with monitoring and reporting CDI program performance through designated metrics, audit findings, and documentation improvement indicators
