Clinical Documentation Specialist II CDI
Location
United States
Posted
5 days ago
Salary
Not specified
Job Description
Role Description
The Clinical Documentation Specialist II improves the accuracy and quality of inpatient medical record documentation to ensure correct DRG assignment, coding integrity, and optimized reimbursement. The role includes:
- Timely chart reviews
- Identification of documentation gaps
- Issuance of clinically sound queries with high response and agreement rates
- Collaboration with providers and interdisciplinary teams
- Maintenance of accurate data in 3M 360 and Epic
- Support for financial and quality review projects
- Mentoring new staff
- Assistance to Rehab services with compliance and tier optimization
Strong clinical reasoning, ICD‑10/DRG knowledge, and communication skills are essential.
Qualifications
- License/Registration/Certification: R.N. or Medical Graduate
- Education: R.N. Certified preferred; Medical School Graduate; Bachelor's Degree
- Experience: Critical Care/Intensive Care patient care experience preferred; medical record (ICD-9) coding and/or prior Clinical Documentation Improvement experience desired
Requirements
- Applies ICD-10 coding guidelines appropriately and has an 85% Working DRG accuracy
- Good working knowledge of all DRG and their structure, as well as CCs and MCCs
- Reviews all patient records in assigned unit(s) between 24-48 hours of inpatient admission
- Manages approximately 16-20 charts daily
- Recognizes opportunities for documentation improvement
- Formulates clinically credible queries to physicians
- Maintains excellent rapport with healthcare providers
- Maintains query rate of 25-35% of all patient records reviewed
- Follows up on all pending queries daily
- Good command of 3M 360 Encompass software
- Responsible for retrospective reviews for quality and revenue projects
- Documents query narrative and notes expected and actual responses
- Responsible for mentoring and training new employees
- Reviews mismatch report periodically
- Supports manager in reconciliation of monthly query reports
- Works individual monthly financial report
- Reports accounts with unanswered queries
- Provides support to Rehab team by reviewing potential rehab admissions
Benefits
- Health benefits
- Life insurance
- Long-term disability coverage
- Healthcare spending accounts
- Retirement plan
- Paid time off
- Pet Insurance
- Tuition reimbursement
- Employee assistance program
- Wellness program
- On-site housing for select positions
- And more!
Job Requirements
- License/Registration/Certification: R.N. or Medical Graduate
- Education: R.N. Certified preferred; Medical School Graduate; Bachelor's Degree
- Experience: Critical Care/Intensive Care patient care experience preferred; medical record (ICD-9) coding and/or prior Clinical Documentation Improvement experience desired
- Applies ICD-10 coding guidelines appropriately and has an 85% Working DRG accuracy
- Good working knowledge of all DRG and their structure, as well as CCs and MCCs
- Reviews all patient records in assigned unit(s) between 24-48 hours of inpatient admission
- Manages approximately 16-20 charts daily
- Recognizes opportunities for documentation improvement
- Formulates clinically credible queries to physicians
- Maintains excellent rapport with healthcare providers
- Maintains query rate of 25-35% of all patient records reviewed
- Follows up on all pending queries daily
- Good command of 3M 360 Encompass software
- Responsible for retrospective reviews for quality and revenue projects
- Documents query narrative and notes expected and actual responses
- Responsible for mentoring and training new employees
- Reviews mismatch report periodically
- Supports manager in reconciliation of monthly query reports
- Works individual monthly financial report
- Reports accounts with unanswered queries
- Provides support to Rehab team by reviewing potential rehab admissions
Benefits
- Health benefits
- Life insurance
- Long-term disability coverage
- Healthcare spending accounts
- Retirement plan
- Paid time off
- Pet Insurance
- Tuition reimbursement
- Employee assistance program
- Wellness program
- On-site housing for select positions
- And more!
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