CDI Specialist (Navy)

| US-SC-Beaufort
Req No
Regular Full-Time


Peak Government Services was formed in 2004 with a single goal: to provide unparalleled coding management solutions and staffing services to our government clients and agencies.


Peak Health Solutions, an AMN Healthcare company, is an EEO/AA/Disability/Protected Veteran Employer We encourage minority and female applicants to apply


Clinical Documentation Improvement Specialist (CDIS) Work Statement


The CDIS Shall:

  • Perform initial and follow-up assessments regarding the inpatient provider’s documentation skills. With each assessment, inpatient record reviews shall include verification of patient identification and demographics; reason for admission; disposition date; assignment of diagnoses; procedures documentation and health care provider’s signature. The CDIS shall also identify opportunities for improvement to ensure documentation used for measuring and reporting physician and hospital outcomes is accurate and complete.
  • Perform a baseline review of all new health care providers within 30 days of seeing patients to determine the current level of documentation detail. The sample size for the review shall be 2% per provider. A report of findings shall be provided to the Task Order Government POC and the COR within 5 business days of starting the review.
  • Concurrently review all medical records to identify documentation deficiencies. For an inpatient stay, the CDIS shall review the provider documentation daily and recommend an addendum to the record if necessary. If the CDIS determines a provider’s documentation is not improving, the CDIS shall recommend a corrective action plan to identify specific areas of improvement, a remediation plan that includes a timeline in which to achieve positive results and a follow-up plan.  The corrective action plan shall be approved by the client prior to implementation.  A summary of all providers placed on a corrective action shall be included in the monthly report of services rendered.
  • Perform focused inpatient medical record reviews. The initial review is performed within 24-48 hours of patient admission.
  • Communicate with physicians, case managers, coders and other health care team members to obtain comprehensive medical record documentation to support the severity of illness, expected risk of mortality, and complexity of care provided to the patient. Documentation obtained shall include clinical treatment and procedures, medical decisions and diagnoses for inpatients.
  • Initiate a query to the health care provider to clarify and explain any documentation that does not clearly and consistently describe the patient’s medical condition and hospital stay to assign the correct MS-DRG. Clarification includes obtaining accurate and complete documentation based on current clinical findings, prescribed treatment, medical interventions and/or processes.
  • Conduct routine (non-query) follow-up reviews of the medical record every 3 days until the issue is resolved.
  • Review outstanding queries daily for provider responses and follow-up as needed to facilitate timely and accurate documentation.
  • Provide education to physicians and other members of the health care team regarding compliant documentation responsibilities, coding and reimbursement issues and documentation guidelines.
  • Investigate and analyze documentation issues/questions to generate and recommend solutions to the client. The CDIS shall prepare formal reports for the government with findings and recommendations regarding documentation, revenue and reimbursement issues. Formal reports shall be submitted to the client by the 5th business day of each month.
  • Provide medical record documentation education to residents and interns in the MTFs Family Practice graduate medical education (GME) program.
  • Implement coding documentation improvement processes and disseminate new/updated information to improve documentation, RWP and Prospective Payment System (PPS) capture within five (5) business days after receiving approval from the client.
  • Educate the health care provider on the most efficient process for capturing data in the applicable system.
  • Evaluate Present on Admission (POA) indicators for each diagnosis that could potentially affect the principal diagnosis, quality indicators or MS-DRG assignment.
  • Monitor compliance with policies and procedures relevant to the clinical data management program and make recommendations to improve compliance, obtain government approval for implementation and take action.
  • Collect and analyze data to correct identified complex coding deficiencies and improve reimbursement capture.
  • Utilize enterprise-prescribed tools to monitor the completeness of clinical documentation and accuracy of code assignments.
  • Make daily rounds and interact with health care team members to ensure consistent documentation practices. The CDIS shall work closely with any department impacting admissions to include, Scheduling, Insurance Verification, Operating Room (OR), Post-Anesthesia Care Unit (PACU), Emergency Department (ED) and the Admitting Office for direct admits. The CDIS shall seek clarification from physicians regarding proper documentation as it relates to reimbursement.


Bachelor’s degree in a health-related field with a minimum of 5 years clinical experience including but not limited to; acute patient care, health services, public health, long-term care administration, hospital organization and management, strategic planning and health systems.


Two years in the last five years focused on inpatient coding, healthcare and coding regulations including code structure, clinical documentation, MS-DRG experience, criteria-based chart reviews (ex. Utilization Management or Case Management), and quality improvement experience working with a physician’s group.


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