Clinical Documentation Improvement Specialist
: Job Details :

Job Purpose:The Clinical Documentation Improvement (CDI) Specialist plays a vital role in ensuring the accuracy and completeness of medical records. This position requires a strong understanding of medical terminology, coding guidelines, and quality improvement principles. The CDI Specialist will work closely with healthcare providers, coding staff, revenue cycle, EMR administrators and analysts and other stakeholders to identify and address documentation issues, improve the quality of care, ensure documentation compliance, and optimize reimbursement.Primary Duties and Responsibilities:• Audits and analyzes medical records, peer-to-peer reviews, and denial information to identify inconsistencies, omissions, or discrepancies identifying trends and patterns that may affect patient care or reimbursement • Reviews documentation practices and processes to understand barriers to complete accurate documentation and works with key stakeholders to develop improvement strategies • Leads implementation of improvement initiatives focused on reducing denials and peer-to-peer requests and maximizing the revenue received for billed services provided• Communicates effectively with physicians and other healthcare professionals to clarify documentation and obtain additional information• Provides training and education to healthcare staff on documentation guidelines and best practices • Collaborates with coding teams to ensure accurate coding and billing • Monitors and reports on the effectiveness of quality improvement initiatives • Ensures compliance with all relevant regulations, including those related to reimbursement, quality, and patient safety • Leads Documentation Improvement Committee bringing Billing, Clinic Operations, and Informatics teams together and attends as needed IT Governance, EEDI, and Billing department meetings. Competencies:• Service: We align our actions and decision making with the organization's guiding platform keeping our patients at the center of all we do.• Change Agent: We support and contribute to positive change in the organization.• Communication and Interpersonal Relations: We communicate honestly and with compassion to build connections with our patients and each other.• Effectiveness: We take ownership of work, doing the right thing for our customer and doing it well.Organizational Culture:All OrthoIllinois employees focus on service by putting the mission, vision, and value statements into practice and using the guiding principles of Compassion, Respect, Trust, Integrity, Innovation, Education Fiscal Responsibility, Practice Independence, Accountability, and Empowerment to direct their interactions and decision making. Employees promote and model the service standards to create lasting impressions, extraordinary moments, exceptional on-stage experiences, and meaningful and compassionate connections. Education and Experience Requirements:• Bachelor's degree in nursing, health information management, or a related field required• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) certification preferred• Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) preferred• Strong understanding of medical terminology and coding guidelines• Orthopedic experience strongly preferred• Familiarity with EMR software, preferably eCWEnvironmental/Working Conditions: Working environment is in an office/clinic setting. Requires occasional work outside of normal business hours, including evenings and weekends.Physical/Mental Demands: • Sit, stand, walk, stoop or kneel, crouch or crawl, and climb stairs for long periods of time• Requires lifting, carrying and/or moving objects in a manner consistent with most office environments (generally, no more than 10 pounds on a frequent basis and 20 pounds on an occasional basis)• Possess full range of motion in shoulders and arms, including reaching above or below the shoulder• Finger dexterity; the ability to twist hands/wrists repetitively• Vision (e.g., depth perception, color vision, strong vision up close), hearing (e.g., high pitch sounds, soft or distant sounds)This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.