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Clinical Documentation Specialist
2 weeks ago
We are seeking a skilled Clinical Documentation Improvement (CDI) Specialist to join our team at GGIS Services. As a CDI Specialist, you will play a crucial role in ensuring the accuracy and completeness of patient records.
Key Responsibilities:
- Review and analyze clinical documentation to ensure accurate reflection of patient care
- Develop and submit clear, concise queries to physicians and healthcare providers
- Collaborate with physicians, nursing staff, and other healthcare professionals
- Review patient records for accuracy in coding and clinical documentation
- Ensure compliance with regulatory requirements related to clinical documentation and coding practices
- Assist in education and training for healthcare providers regarding proper documentation practices
- Provide feedback on documentation deficiencies and opportunities for improvement
Requirements:
- Strong knowledge of anatomy, pathophysiology, disease processes, and management
- Inpatient CDI experience in a specialized area (acute care setting)
- Coding knowledge required: ICD-10-CM & PCS, Clinical codes and compliance, DRGs with MCCs, CCs, SOI, ROM, APR-DRG, and MSDRG
- AHIMA certification required (CCS credential)
- ACDIS certification required (CCDS and/or CDIP)
- Expertise in creating queries based on clinical documentation and familiarity with English grammar/written skills
