Job Description

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 me dical 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.

• Inpatient /Observation Cases

• All diagnosis and procedure assigned ICD-10-CM and ICD-10 PCS codes
• Discharge disposition assigned
• Assigned Present on Admission (POA) indicators
• APR-DRG, MS-DRG, SOI, and ROM assignment for inpatient cases
• Appropriateness of queries created

Outpatient Cases (ER, SDS, Ancillary)

• All diagnosis and procedure assigned ICD-10-CM and ICD-10 PCS codes
• All CPT assigned codes
• Modifier use and assignment
• APC assignment

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.