The Clinical Documentation Improvement Specialist (CDIS) implements clinical documentation improvement (CDI) activities in an effort to support accuracy and quality of the patient records at facilities and to ensure that coded diagnoses are an accurate reflection of the patient’s clinical status and care. The role of the CDI specialist involves reviewing the medical record documentation and clinical indicators and working with providers to ensure a complete and accurate medical record. An accurate medical record is important for the patient, for continuity of care by the next provider, and to demonstrate high quality care by the physician and the hospital. The CDI Specialist will identify potential gaps in clinical documentation for inpatient and payer populations as directed throughout the hospitalization. He/she will also educate physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record
Required Skills & Experience
– RN or greater (NP, PA, etc.)
– BSN
– CDI experience (1- 2 years)
– Must possess at least five years of acute hospital nursing experience
– Experience in Utilization Management/Case Management, Critical Care, patient
outcomes/quality management and/or inpatient coding considered a plus.
– Prior experience in clinical documentation improvement, ICD coding and MS-DRGs
preferred.
– Prior experience educating physicians/providers preferred.
– Previous experience working in a clinical documentation improvement department or
as a consultant strongly encouraged.
– Minimum of one-year auditing experience strongly encouraged.
– This individual must possess a comprehensive knowledge of medical terminology,
disease processes and clinical competency.
– The following are preferred: RHIT, RHIA, CDIP, CCDS, CCS and ICD-10 certification
or designation.
Reference : Clinical Documentation Specialist (CDIS) jobs
Source: http://jobrealtime.com/jobs/technology/clinical-documentation-specialist-cdis_i4410
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