Clinical Document Integrity (CDI) Specialist

Responsibilities: Perform concurrent and retrospective reviews of inpatient medical records to ensure documentation accuracy and quality. Collaborate with physicians through compliant query practices to optimize code assignment, severity of illness, and reimbursement.

Requirements: Requires an active RN license and at least three years of recent CDI experience in a Level I Trauma Academic Medical Center. Proficiency in ICD-10-CM/PCS guidelines and MS-DRGs is essential.

Key skills: Clinical Documentation Integrity, ICD-10-CM/PCS, MS-DRGs, Physician Querying, Medical Record Review, Severity Of Illness, Risk Of Mortality, Epic EHR, Concurrent Review, Retrospective Review, Clinical Collaboration, Critical Thinking, Analytical Skills, Communication Skills, Patient Outcomes, Healthcare Documentation

Keywords: CDI, RN, CCS, CIC, CDIP, CCDS, ICD-10-CM, ICD-10-PCS, MS-DRG, Severity Of Illness, Risk Of Mortality, Epic, Level I Trauma Center, Academic Medical Center, Clinical Documentation Improvement, CMS Regulations, Coding Clinic, Medical Coding, Healthcare Consulting, Inpatient Review