Clinical Documentation Informatics Specialist

The Clinical Documentation Informatics Specialist, also referred to as CDI Coordinator, under the guidance of CDI leadership, assists with clinical documentation initiatives for the hospital or health system, including CDI program support, special projects or process implementation, and continuous process improvement. Reviews medical records to facilitate specific and clear physician documentation so that it may be coded accurately.  Serves as a CDI resource for Clinical Documentation Specialists, physicians, CDI leaders, and others in support of clinical documentation improvement initiatives.  

DOCUMENTATION REVIEW 

• Performs concurrent and/or retrospective CDI review of acute inpatient medical records for clarity and specificity of physician 

• Places queries for physicians in the medical record, requesting clarification of the principal diagnosis or secondary conditions of the patient. 

• Serves as a CDI resource to physicians, CDI staff, coders, and other stakeholders regarding documentation improvement initiatives, CDI workflows, and documentation best practices.

• Performs CDI audits to identify trends or problem areas for documentation and coding. 

• Collects, analyses and/or prepares CDI metrics, documentation trends, and other designated program measures to support process improvement initatives. Assit with monitoring and tracking CDI processes and related outcomes.

QUALITY

• Operates within the compliance guidelines of Medicare and Medicaid Services.

• Always considers compliance and displays ethical decision-making skills. 

• Knows, understands, and complies with applicable federal and state laws, Corporate Compliance policies and procedures, reporting requirements, accrediting body standards, and organizational compliance expectations.

COLLABORATION AND PARTNERSHIP

• Works collaboratively with CDI leadership, CDI staff, coding professionals, physicians, and other stakeholders to support documentation improvement initiatives and program goals.

• Works collaboratively with departments, vendors, and external partners on CDI initiatives, special projects, and process improvement activities supporting documentation integrity and organizational objectives, as directed by CDI leadership.

• Functions as a CDI team resource. Assists with problem solving and CDI initiatives including process improvements and the implementation and support of new processes. 

• Serve as a liaison between CDI operations, coding, information systems, vendors, and organizational stakeholders to support CDI technology, workflows, and processes, as directed by CDI leadership. 

RESEARCH AND EDUCATION

• Assists with the design, development, implementation, and testing of workflows, tipsheets, educational materials, query templates, CDI reference tools, and special project content supporting the CDI program.   

• Assists CDI leadership with development and maintenance of reports, audits, dashboards, tracking tools, and educational resources used to monitor CDI program performance.

• Assists CDI leadership with monitoring and reporting CDI program performance through designated metrics, audit findings, and documentation improvement indicators.

• Performs CDI audits as designated, supporting CDI leadership for in identifying and addressing educational opportunity for CDI specialists and coders.  

• Assists with testing, implementation, optimization, and ongoing suppport of CDI software, reporting tools, workflows, and system enhancements.

Required Experience

Five (5) years of combined experience in either:

• Clinical nursing and Clinical Documentation Integrity (CDI), or
• Acute care inpatient coding and Clinical Documentation
•  Integrity (CDI)

Along with experience in CDI auditing, CDI secondary level reviews, and/or CDI metric analysis. 

Required Education

• Graduate of an accredited school of nursing or
• Associate’s degree in Health Information Management (RHIT) and  2 years of applicable experience, or
• Bachelor's degree in Health Information Management

Certification/Licensure: Active RN license or Certified Coding Specialist credential (CCS)