• CDI Specialist

    Job Locations US-SC-Columbia
    Req No
    Production Coding
  • Overview

    Facilitates appropriate clinical documentation to support diagnosis capture and to ensure the level of service rendered to all patients is recorded. Identifies and reviews primary and secondary diagnosis and complications to ensure diagnosis documentation and capture through addendums may identify patients who need to be seen. Identify and review for POA (Present on Admission) documentation. Reviews clinical issues with medical coding staff and with physicians to identify those diagnoses that impact severity of illness indicators for each patient. Perform CDI QA reviews, both concurrent, prebill and retrospective


    Serves as an expert resource in reviewing all medical records in support of consistent documentation for all payer types (i.e. CMS, Medicare-Advantage, etc) to ensure complete and accurate diagnosis capture and coding. Collaborates in the development of programs which provide alignment with education for internal customers to support clinical documentation guidelines. Communicates information effectively with medical center leaders. Works with Coding Review Manager to develop, implement and monitor departmental policies and procedures that support organizational goals, business objectives, regulatory needs and requirements. Conducts data and root cause analysis, provides feedback and shares findings on the analysis to leaders, local regional management and medical team. Monitor and track verbal and written queries and produce reports as required.


    *Education:  Bachelor’s degree (BS, BSN, BS-HIM), Masters preferred.  
    *Licensure/Certification:  Licensed Registered Nurse (RN), Registered Health Information Management Administrator (RHIA), Registered Health Information Management Technician (RHIT), Clinical Coding Specialist (CCS)or combination thereof preferred
    *Professional Experience:  Prior experience in inpatient coding, clinical documentation improvement, and/or case management preferred. Minimum of five years’ experience in a clinical role and a minimum of two years’ experience with inpatient coding, process improvement in an acute care facility preferred or equivalent experience.  Coding skills with experience in ICD-10-CM, knowledge of CMS Inpatient Prospective Payment System, and working knowledge of AHA Coding Clinics. Certified Clinical Documentation Improvement Specialist (CCDS) or Certified or Certified Documentation Improvement CDI Practitioner credential preferred. Excellent oral, written and communication skills. Current working knowledge of one or more of the following: Cardiac Thoracic Surgery, Medical / General Surgical, Critical Care, Care Management (Resource Utilization), Surgical Services, Accreditation and Regulatory Compliance, Quality Measures, Hospital Acquired Conditions and Public Reporting of Hospital Quality Data. Experience in development of reference based continuing educational programs using Adult Learning Principles

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


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