CDI Specialist

Job Summary We are seeking a dynamic and detail-oriented CDI (Clinical Documentation Improvement) Specialist to join our healthcare team. The purpose of this role is to improve overall quality and completeness of medical clinical documentation to substantiate medical necessity of services and facilitate accurate coding through extensive interaction with physicians, case managers, nursing staff, quality professionals, HIM professionals, and other patient caregivers.

Education & Qualifications:

Graduate of an accredited School of Nursing, BSN preferred

Required Licenses/Certifications:

• Licensed as a Registered Nurse in the state of Texas preferred.
• Certification in Clinical Documentation Integrity from

ACDIS, AHIMA, or AAPC Work Experience:

§ Three to five years of inpatient and outpatient hospital CDI experience § Utilization Review experience including applying Interqual and Milliman Care Guidelines (MCG) along with payer specific medical guidelines and how to apply them to an appeal § Experience reviewing and analyzing denied/downgraded MS-DRG and APR-DRG accounts received from payers (i.e.: Medicare, Commercial, and Third Party) § Working knowledge of billing codes, revenue codes, CPT's, ICD-10 CM/PCS § Experience and knowledge of managed care contracts, account receivables and revenue cycle functions § Working knowledge of provider billing guidelines, payer reimbursement policies, and related industry-based standards.

Responsibilities:

• Collaborate with case management, coding, and quality teams to ensure continuity of care and accurate data reporting.
• Educate medical staff on the importance of compliant, thorough documentation.
• Issue compliant, timely queries to physicians and healthcare providers to clarify diagnoses, procedures, and treatments.
• Work alongside Case Management to evaluate admission, concurrent, and retrospective patient charts to determine medical necessity and appropriate level of care.
• Ensure documentation accurately captures the Severity of Illness (SOI) and Risk of Mortality (ROM).
• Write clear and concise letters, handle necessary technical vocabulary, and organize difficult or complex information in an understandable and efficient manner
• Serves as a liaison with third party payer and agencies regarding appeals to ensure optimal reimbursement and any other billing or payment issues and ensuring issues are resolved
• Develops recommendations to maintain efficient and effective processes
• Identifies coding and clinical documentation issues and provide recommendations
• Updates patient account record to identify actions taken on account
• Responsible for favorable resolution of third-party payment details, adverse determinations, medical necessity denials, payment discrepancies, and contract misinterpretations
• Review whether DRG's are assigned correctly and if all diagnosis and procedures are identified and documented
• Identify trends and/or opportunities to improve clinical documentation.
• Provides education to the providers regarding clinical documentation improvement and the need for accurate and complete documentation in the patient record
• Works with HIM, Finance and physician groups to develop systems to facilitate complete documentation for data reporting
• Serves as a resource to physicians, case managers, and other key professional staff in matters relating to published DRG information
• Consistently meets established productivity targets for medical record review
• Perform other duties as assigned

Pay:

$42.00 - $55.00 per hour

Benefits:

401(k) 401(k) matching Dental insurance Disability insurance Employee assistance program Employee discount Flexible spending account Free parking Health insurance Life insurance Paid time off Referral program Tuition reimbursement Vision insurance

Work Location:

In person