Clinical Documentation Improvement Specialist
Clinical Documentation Improvement Specialist
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1 Vacancy
Job Description
Join Us as a Clinical Documentation Improvement Specialist!
Schedule: Monday-Friday 40 hours per week
On Site at TaraVista Devens MA
The CDI Specialist is responsible for the overall improvement of the quality completeness and accuracy of medical record documentation through interaction with providers. They ensure clinical documentation reflects the level of service and severity of illness. They make sure that the patients chart reflects their complete stay and that chart data translates into coded data to effect reimbursement.
As a Clinical Documentation Improvement Specialist:
- Collaborate extensively with physicians nurses other caregivers and medical records coding staff to improve quality and completeness of documentation of care provided.
- Collaborate with HIM Director to implement departmental quality improvement initiatives.
- Assist in the collection and analysis of risk adjustment data in order to identify documentation coding trends and opportunities.
- Audit medical records for accuracy of coding conflicting or incomplete documentation.
- Assign audit and reporting duties to HIM staff and unit coordinators.
- Conduct concurrent review of the medical records to increase the accuracy clarity and specificity of provider documentation.
- Provide feedback to providers and external/internal business partners of audit findings and make recommendations as necessary.
- Develop and coordinate education and training pertaining to coding and documentation opportunities utilizing a variety of methods to deliver content such as direct provider collaboration power point presentations and Teams meetings.
- Partner with key business areas around provider education engagement and develop follow up plans where appropriate.
- Keep current with changes in coding guidelines compliance reimbursement and other relevant regulatory updates.
- Proficiency with CDI software and electronic health records (EHR) systems.
- May require 5% travel to our second hospital TaraVista Behavioral Health in Devens MA for collaboration and planning.
The Clinical Documentation Improvement Specialist will have the following:
- Associates degree in health information management Nursing or a Medical Coding or healthcare related field (or equivalent combination of formal education and experience).
- Possession of AHIMA (American Health Information Management Association) or AAPC (American Academy of Professional Coders) of any of the following:
- Certified Documentation Integrity Practitioner (CDIP)
- Certified Clinical Documentation Specialist (CCDS)
- Certified Coding Specialist (CCS)
- Certified Risk Adjustment Coding (CRC)
- RHIT - Must have critical thinking analytical and problem-solving skills.
- Highly organized with strong project/task management skills.
- Possess knowledge of federal state and payer specific regulations policies and guidelines pertaining to coding documentation requirements and billing.
- Experience with EHR systems and reporting.
- Advanced knowledge of Microsoft Office.
When you join the growing TaraVista team as a Clinical Documentation Improvement Specialist youll receive:
Medical Dental and Vision
401(k) match
Employer paid long term disability (LTD)
Short term disability (STD)
Employer paid life and AD&D Insurance
Generous Paid Time Off
Flexible Spending Account
Tuition Reimbursement
TaraVista is an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race color religion age sex national origin disability status genetics protected veteran status sexual orientation gender identity or expression or any other characteristic protected by federal state or local laws.
Required Experience:
Unclear Seniority
Employment Type
Full Time
