Senior Clinical Documentation Improvement Specialist
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Job Description
Senior CDI Specialist improving inpatient medical-record documentation integrity at Mercy. Reviewing records, educating providers, and supporting healthcare quality and compliance initiatives.
Responsibilities:
- Conduct reviews of inpatient medical records to identify missing, vague, or incomplete documentation
- Communicate the need for additional documentation to appropriate clinical providers and/or coding
- Ensure additional documentation is completed in a timely manner
- Collaborate with coding, quality, compliance, medical staff, utilization review/case management, and other applicable departments
- Improve the quality of provider documentation
- Support initiatives to improve documentation quality by all caregivers
- Provide data reports and educational support on required documentation elements to inpatient healthcare providers
- Assist in special projects and committees
- Mentor lower-level CDI Specialists
- Perform duties consistent with Mercy’s mission, values, and Service Standards
Requirements:
- RN, BSN, RHIA, RHIT, CCS, CPC, CIC, CCDS, or CDIP
- 3 years CDI experience and 1 year in nursing, inpatient coding, UM, CM, Quality, or related field
- Demonstrates proficiency of the Clinical Documentation Specialist role
- Detailed data analysis and ability to present complex data or education to providers individually or in front of a group
- Excellent critical thinking skills and reading comprehension
- Strong clinical knowledge and ability to identify diagnoses based on clinical data
- Extensive knowledge of disease processes and clinical outcomes
- Experience with Excel, Word, and PowerPoint
- Advanced knowledge of healthcare regulations, including reimbursement, documentation requirements, and quality measures
- Skilled in record review with ability to interpret clinical data
- Excellent written and verbal communication skills and comfort speaking in groups
- Ability to plan and organize workflow to meet deadlines
- Strong computer skills including typing ability
- Ability to produce reports using multiple formats and software
- Ability to interpret data reports and present findings to medical staff committees as needed
- Ability to establish cooperative working relationships with diverse groups, medical staff, and healthcare disciplines
- Ability to mentor lower-level CDI Specialists
- Ability to work flexible schedules to accommodate provider rounding schedules and required medical staff presentations
- Ability to work with minimum supervision, function in a stressful environment, maintain confidentiality of sensitive information, and support team building
- Preferred: 3–5 years CDI experience
- Preferred: CCDS from ACDIS or CDIP from AHIMA
Benefits:
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Tuition support
- Matched retirement plans for team members working 32+ hours per pay period
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