Oversees the functions of assigned Clinical Documentation Improvement (CDI)
staff to meet the needs of the section. Act as content expert for section
based upon a solid knowledge of clinical documentation, ICD-10AM coding
requirements, and AR-DRG guidelines.
1. Oversees assigned CDI staff to ensure an advanced level review of
inpatient medical records to identify gaps in clinical documentation.
2. Provides advanced level review of inpatient medical records to identify
gaps in clinical documentation. Provides guidance to ensure consistency of
review of clinical documentation.
3. Follows up communication with the healthcare providers regarding existing
clarifications to obtain needed documentation specification.
4. Conducts and encourages engagement with healthcare providers in ongoing
educational sessions in regards to documentation improvement. Prepares and
shares reports on any recurrent gaps, lack of compliance, and findings in the
medical records to CDI manager.
5. Engages medical staff in the process of reviewing clinical documentations
for better awareness and smooth knowledge transfer.
6. Evaluates sub ordinary 's performance and productivity on a monthly basis
based on defined KPIs and performs ad-hoc reviews, and counsels them on areas
of improvement.
Master 's or Bachelor's Degree in Nursing, Health Information Management or
other Healthcare related discipline is required.
Four (4) years of related experience with Master 's, or six (6) years with
Bachelor's Degree is required.
? Certified Clinical Documentation Improvement or Health Information
Management is preferred.
? Experience as an RHIA, CCC, CHIM and/or verifiable documentation review
experience gained in a tertiary care setting is preferred.
? Certified Medical Coder (AR-DRG) is preferred.
? Experience with medical insurance is preferred.
? Deep knowledge of medical documentation.
Responsible for reviewing medical records for completeness by monitoring the healthcare providers' compliance about recording the patient's medical related data (treatments, medications, requests) to support the accurate assignment of codes. ##### **Essential Responsibilities and Duties** 1\. Prov…
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