Clinical Documentation Specialist CDI

About This Role

This role focuses on ensuring accurate, complete, and clinically supported documentation in inpatient medical records, reflecting the severity of illness, quality outcomes, and reimbursement integrity. The specialist identifies documentation opportunities, develops compliant provider queries, and collaborates with various healthcare teams to resolve documentation and DRG discrepancies. At a senior level, the role involves handling complex cases, contributing to departmental projects, analyzing documentation trends, and mentoring team members.

Responsibilities

• Apply ICD-10 coding guidelines appropriately and maintain an 85% Working DRG accuracy
• Possess good working knowledge of all DRGs and their structure, as well as CCs and MCCs
• Discern the impact of a query to focus efforts efficiently and determine priorities
• Review all patient records in assigned unit(s) between 24-48 hours of inpatient admission and subsequently every 2-3 days until discharge, as needed
• Manage approximately 16-20 charts daily
• Recognize opportunities for documentation improvement by utilizing sound clinical reasoning, critical thinking skills, and coding concepts
• Formulate clinically credible queries to physicians and achieve a response rate and agree rate above 85% respectively
• Maintain excellent rapport and working relationship with physicians, residents, physician assistants, nurse practitioners, nurses, case managers, and other healthcare providers
• Maintain a query rate of 25-35% of all patient records reviewed
• Follow up on all pending queries daily until answered and monitored
• Manage Epic query workqueues as well as 3M 360 pending queries swim lanes regularly
• Possess good command of 3M 360 Encompass software and maintain accurate data input of patient's working DRG and baseline DRG
• Record daily review notes and all other required notes within the software accurately
• Conduct retrospective reviews for quality and revenue projects as assigned
• Properly document query narrative and note the expected query response and the actual response including date and location of response in the medical record
• Mentor and train new employees in conjunction with the department Manager
• Review the mismatch report periodically to ensure working DRGs are optimal and address any discrepancies with HIM coding staff in an effective and timely manner
• Support manager in reconciliation of monthly query reports and other financial reports as needed
• Work individual monthly financial report to ensure accounts with financially impacting queries have the proper baseline DRG and that final DRG and working DRG match to ensure reporting is optimal
• Report accounts with unanswered queries that would have otherwise impacted DRG weight for tracking