Essential Job Functions:
Initial Audit and Education: For assigned coding staff, conduct initial quality audits as they go through onboarding process for new project / client assignment, and provide education to staff based on initial quality audit findings. Review medical records for accuracy of coding and data quality.
Elements included in reviews may include:
• CDI audit reviews • Auditing: Reviewing medical records, including clinical notes, lab results, and other diagnostic information, to ensure documentation accurately reflects diagnoses, severity of illness, and risk of mortality. • Compliance: Ensuring documentation complies with regulatory requirements, coding guidelines, and payer rules. • Identifying Gaps: Identifying missed documentation opportunities, inconsistencies, and areas where documentation can be more specific or clarified. • Query Review: Evaluating the appropriateness of queries issued to physicians, ensuring they are supported by clinical evidence and aligned with coding guidelines. • Data Analysis: Analyzing data related to CDI performance, identifying trends, and reporting findings to leadership. • Education and Training: Providing education and training to CDI staff, physicians, and other healthcare professionals on documentation best practices, coding guidelines, and regulatory requirements.
Skills and Qualifications:
Clinical Knowledge: Strong understanding of disease processes, clinical conditions, and medical terminology.
Coding Knowledge: Familiarity with ICD-10-CM/PCS, CPT, and other relevant coding systems.
CDI Experience: Experience in clinical documentation integrity, including chart review and query writing.
Analytical Skills: Ability to analyze data, identify trends, and make recommendations for improvement.
Communication Skills: Excellent written and verbal communication skills to effectively communicate with various healthcare professionals.
Qualifications for Internal Candidates:
Employee must be fluent in auditing facility inpatient, Outpatient is a plus. Will be trained in DRG appeal writing. Must be experienced in Word and Excel. CDI credential is a plus.