Job Summary:
The Clinical Documentation Improvement (CDI) Specialist primary responsibility is to ensure the inpatient medical record accurately supports severity of illness and risk of mortality, as well as reflects the extent of care being provided and the resources being utilized for patients within the University Hospital system, utilizing comprehensive and broad proficiency in complex clinical and medical concepts. This is achieved by both thorough comprehensive concurrent and retrospective medical record review for accuracy, specificity, and validation of clinical diagnoses through application of clinical, documentation, and ICD-10 coding conventions, as well as Centers for Medicare and Medicaid Services (CMS) rules and regulations. When inconsistencies, incomplete documentation, or opportunity for medical record clarification or optimization are identified, the CDI Specialist will collaborate with the medical team to clarify necessary items through a dedicated and compliant ...