Job Description

• Review clinical documentation to ensure it accurately reflects the patient's severity of illness, risk of morality, and complexity of care.
• Share review findings with leadership, CDI team, and other relevant staff; recommends correct actions needed
• Performs focused reviews on specific areas like mortality rates, patient safety indicators (PSIs), and other priority projects
• Provides ongoing education and training to the CDI team and related departments about documentation trends and best practices. Also leads the onboarding of new CDI specialists.
• Acts as a subject matter expert in CDI, coding rules, and compliance, identifying risks and opportunities for improvement.
• Applies coding guidelines and policies to assign accurate DRGs and reviews patient records through hospitalization to ensure proper coding.
• Collaborates with physicians to clarify unclear or missing documentation through queries or during rounds
• Works with HIMS coders to ensure accurate diagnosis/procedure codes and complete documentation for final DRG assignment and quality outcomes.
• Builds and maintains strong relationships with providers to support documentation improvement efforts.
• Leads documentation improvement initiatives and participates in related department or organizational projects