CDI Specialist - Pointwest Technologies Corp

Position: Clinical Documentation Improvement (CDI) Specialist

Location: Remote or Onsite

Joining Team: Revenue Cycle Management (RCM)/Healthcare

Role Overview:

Pointwest Technologies Corporation seeks a dedicated and proficient CDI Specialist to join our dynamic RCM/Healthcare team. In this pivotal role, you will conduct concurrent and post-discharge reviews of targeted inpatient medical records to ensure comprehensive and accurate documentation.

Key Responsibilities:

1. Concurrent Reviews: Conduct initial and secondary reviews on selected admissions. Document findings meticulously.
2. Chart Review and Quality Maintenance: Review 18-25 patient charts daily, ensuring new admissions are reviewed within 24-48 hours. Maintain an average chart review quality score of 85% for concurrent reviews.
3. Diagnosis Assignment and Evaluation: Assign principal and secondary diagnoses. Identify CC/MCC and evaluate the severity of illness (SOI) and risk of mortality (ROM) in all patients.
4. Case Identification and Escalation: Identify, flag, and escalate cases with Patient Safety Indicators (PSI 90) and Hospital Acquired Conditions (HAC).
5. Ongoing Medical Record Review: Conduct thorough ongoing reviews of designated medical records to record all evaluated, monitored, or treated conditions.
6. Timely Patient Review: Complete initial reviews within 24-48 hours of admission and subsequent reviews every 24-48 hours. Enter findings in the 3M software system.
7. Case Prioritization Criteria: Assist in establishing criteria for case prioritization.
8. Communication and Documentation: Communicate with medical staff and caregivers for accurate and complete physician documentation. Adhere to AHIMA Standards of Ethical Coding for documentation clarification.
9. Hospital Policy Adherence and Querying: Adhere to hospital policies for clinical condition documentation. Concurrently query physicians to maintain a minimum percentage of reviews.
10. Utilization of Software Tools: Utilize electronic medical records and/or 3M's proprietary software for CDI review, data entry, reporting, and query tracking.
11. Knowledge Application and Self-Education: Apply official coding guidelines and regulatory requirements to improve documentation quality. Engage in ongoing self-education through 3M training and external resources.
12. Certification Maintenance and Advancement: Maintain CCS/CIC certification and work towards obtaining CCDS or CDIP certification.

Qualifications:

• Proven experience in clinical documentation improvement.
• Familiarity with 3M software and electronic medical record systems.
• Strong understanding of coding guidelines and healthcare regulations.
• Excellent communication skills, both written and verbal.
• Ability to work effectively in both team and independent settings.
• Required certification: CCS/CIC, with the goal to obtain CCDS or CDIP.

Join Us:

At Pointwest Technologies Corporation, we value diligence, precision, and a collaborative spirit. As a CDI Specialist on our team, you will play a crucial role in enhancing the quality of patient care through meticulous documentation and coding practices. If you are ready to impact the healthcare industry significantly, we invite you to apply for this exciting opportunity.