Here, you will make an impact by:
As an CDI , The Clinical Documentation Integrity (CDI) Specialist is responsible for reviewing inpatient medical records to ensure accurate, complete, and compliant clinical documentation that reflects the severity of illness (SOI), risk of mortality (ROM), quality outcomes, medical necessity, and appropriate reimbursement. The CDI Specialist collaborates with physicians, coding professionals and other healthcare team members to improve documentation quality and support accurate code assignment and DRG integrity.
• Perform concurrent and/or retrospective reviews of inpatient medical records for documentation accuracy, completeness, and compliance.
• Maintain an accuracy rate of 98%
• Identify opportunities for clarification of diagnoses, procedures, present on admission (POA) indicators, severity of illness, risk adjustment, and clinical validation.
• Initiate compliant physician queries to clarify conflicting, incomplete, or nonspecific documentation.
• Collaborate with coding staff to ensure accurate ICD-10-CM/PCS coding and MS-DRG/APR-DRG assignment.
• Monitor documentation trends related to mortality, quality indicators, hospital-acquired conditions (HACs), patient safety indicators (PSIs.
• Conduct clinical validation reviews for diagnoses such as sepsis, respiratory failure, encephalopathy, malnutrition, acute kidney injury, and other high-risk conditions.
• Maintain productivity and quality standards established by Solventum/facility Query rate of 35-40%, review rate of 20-25 cases per day and an accuracy rate of 98%
• Participate in multidisciplinary rounds, provider education, and documentation improvement initiatives.
• Assist with denial prevention by supporting documentation integrity initiatives.
• Stay current with CMS, ICD-10, AHA Coding Clinic, and organizational compliance standards.