Clinical Documentation Improvement Specialist
New Position in the State of Washington
Cooper Thomas, LLC, a leading provider of clinical documentation improvement, medical coding, and auditing services to For-Profit and Not-For-Profit Health Care and Hospital Systems, has an immediate opening for a full-time, experienced CDI Specialist to support a growing CDI program. The ideal candidate will have no more than 2 years’ experience. Preference will be given to CDI specialists with Cerner software, OBGyn, and Surgery experience.
Please note that this is a hybrid position. The successful candidate will be able to work remotely 4 days a week and will be required to be onsite 1 day a week. All applicants must live within reasonable commuting distance of our client. The successful candidate will qualify for a signing bonus. Applicants must be United States citizens and may be required to undergo a limited background investigation.
Education and Certification
Applicants must have a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) credential through the American Health Information Management Association (AHIMA), or a Certified Professional Coder (CPC) credential through the American Academy of Professional Coders (AAPC).
CDI Specialists must maintain at least one of the following certs from either AHIMA or ACDIS:
- Clinical Documentation Improvement Practitioner (CDIP)
- Certified Clinical Documentation Specialist (CCDS)
Applicants must provide proof of certification at the time of application.
In addition, candidates must hold one of the following degrees:
- Bachelor of Science in Nursing (BSN)
- Registered Nurse (RN)
- Physician Assistant (PA)
Candidates must be credentialed/licensed through or have a degree from a school accredited from one of the following organizations:
- The Comm on Accreditation for Health Informatics and Info Mgmt Education (CAHIIM)
- Educational Commission for Foreign Medical Graduates (ECFMG)
- Commission on Graduates of Foreign Nursing Schools (CGFNS)
- Accreditation Commission for Education in Nursing (ACEN)
- The Commission on Collegiate Nursing Education (CCNE)
- The Liaison Committee on Medical Education (LCME)
- The American Medical Association (AMA)
- The Commission on Osteopathic College Accreditation (COCA)
- The American Osteopathic Association (AOA)
- The Accreditation Review Commission on Education for the Physician Assistant (ARC-PA)
Candidates must have:
- No more than of 2 years CDI experience in an acute care hospital setting, with experience in ICD10-CM/PCS and MS-DRGs.
- Previous OBGyn and Surgery experience are a ++.
When applying for the position:
- Candidates must provide copies of certificates and a resume evidencing 2 years of CDI experience within the last 3 years.
We are looking for a candidate who has a working knowledge of:
- Disease processes, clinical indicators, pharmacology medical terminology and usage, including general medical, surgical, pharmaceutical, hospital terms and abbreviations, and abstracting techniques.
- Official 10-CM, ICD-10/PCS, CPT, APC, DRG and client specific Coding Guidelines for coding and reporting. Preference will be given to applicants with previous coding experience.
- Healthcare regulations, including reimbursement and documentation requirements for severity of illness, risk of mortality, quality outcomes, accurate coding, and DRG assignment.
To be successful in this position, the CDI Specialist must be able to:
- Complete initial medical record reviews of patient records within 24-48 hours of admission for specified patient population to (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnosis, and procedures for accurate DRG assignment, risk of mortality and severity of illness, and (b) initiate a review sheet.
- Conduct follow-up reviews of patients every 2-3 days to support and assign a working or final DRG assignment upon patient discharge.
- Meet average productivity of 3.1x per hour based upon the expected number of initial and subsequent concurrent reviews each month.
- Formulate physician queries regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record.
- Collaborate with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on the topic of documentation and to resolve physician queries prior to discharge.
- Review and verify component parts of medical record to ensure completeness of documentation requirement and accurate assignment of medical codes for diagnosis, operations, and special therapeutic procedures that must conform to the Official Guidelines for Coding and Reporting, and site-specific Coding Guidelines. Code primary diagnosis, co-morbidities, complications, therapeutic and diagnostic procedures, supplies, materials, injections, drugs, modifiers, and units of service etc. with ICD-10-CM, CPT, HCPCS, all Evaluation and Management (E/M) levels, and any other coding that may be required including local client policy.
- Identify the correct primary diagnosis, primary procedure, DRGs and POA indicators based on physician's medical record documentation and establish sequencing rules and applicable guidelines. Ensure proper sequencing of ICD-10-CM/PCS codes proper resource for inpatient records and CPT/HCPCS for surgery charts. Identify additional diagnoses/procedures (e.g., complications, co-morbidities, therapeutic procedures, and diagnostic procedures).
- Analyze and verify the reason for the encounter, including cause(s), primary diagnosis, primary procedure(s), performed and significant related conditions to assure record contents meet the CMS Physician Documentation Guidelines (95 and 97), Joint Commission, and other nationally recognized regulation requirements for the highest attainable quality.
- Validate and manage code corrections of the diagnosis, evaluation and management, procedures or any other codes required for the complete and accurate preparation of the Standard Inpatient Data Record (SIDR).
- When documentation of the medical record is not adequate to identify the appropriate code, query physicians, face-to-face or via clinical documentation inquiry forms regarding missing, unclear or conflicting documentation such as operation/procedure reports to ensure diagnosis, procedure and DRG code assignment.
- Provide education and feedback to providers and other members of the healthcare team to ensure understanding of documentation guidelines of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG.
- Train physicians, coders, or ancillary staff on improvement as needed.
Cooper Thomas, LLC is a leading provider of health information management services. Established in Washington, DC in 2003, Cooper Thomas offers a competitive salary and benefits package, and the opportunity for growth. You will receive annual pay increases. Equal opportunity employer.
IMPORTANT NOTE: To apply, please go to the “Careers” section of our website at www.cooperthomas.com, and follow the instructions to register and apply.
Last updated on Feb 5, 2024