Job Description

The CDIS utilizes advanced clinical knowledge and strong understanding of ICD-10 coding guidelines and documentation requirements to perform comprehensive concurrent reviews to ensure documentation accurately reflects the patient’s severity of illness, risk of mortality, and the complexity of care delivered. The CDIS plays a key role in supporting appropriate reimbursement, accurate quality metrics, and compliance with regulatory standards. SGHS is a Vizient partner that currently utilizes Oracle EMR and Nuance CDI software.

Essential Responsibilities:

This description of job responsibilities is intended to reflect the major responsibilities and duties of the job, but is not intended to describe minor duties or other responsibilities as may be assigned from time to time.

• Conduct concurrent clinical documentation reviews to assess the completeness and clarity of provider documentation for coding accuracy, quality outcomes, and regulatory compliance.
• Perform initial reviews within 24–48 hours of admission and continued stay reviews at least every three (3) acute care days for identified patient populations.
• Analyze the medical record to identify discrepancies and documentation gaps in diagnoses and clinical data included but not limited to laboratory and imaging findings, nursing and dietary notes, therapy and respiratory assessments, pharmacy profiles, consults, physician orders, and therapeutic interventions.
• Formulate and issue compliant physician queries in accordance with ACDIS Guidelines for Achieving a Compliant Query Practice when documentation is ambiguous, inconsistent, or lacking clinical support.
• Assign working MS-DRG using ICD-10-CM/PCS coding guidelines and conventions including accurate assignment of principal diagnosis, pertinent secondary conditions, and procedures.
• Participate in documentation reviews and initiatives related to quality metrics such as HAC, Elixhauser comorbidities (ELIX), and expected mortality outcomes.
• Collaborate with physicians, coding staff, and interdisciplinary teams to support documentation improvement initiatives and accurate code assignment.
• Utilize EHR and CDI software systems to perform concurrent reviews, generate queries, and maintain records according to established CDI workflow processes.
• Maintain performance targets related to review volume, query accuracy, and documentation quality metrics.
• Remain current on CDI industry best practices, coding changes, and federal regulations affecting documentation and reimbursement.
• While most responsibilities can be performed remotely using the hospital’s EHR and CDI software systems, flexibility in hours is required to accommodate collaboration and documentation discussions with providers.

Minimum Qualifications:

• Graduate of LPN Certificate/Diploma, or RN Associate’s or Bachelor’s Degree or an Associate’s/ Bachelor’s Degree in Health Information Management.
• Minimum three (3) years of inpatient CDI experience AND five (5) years of recent acute care nursing experience or five (5) years of inpatient coding experience required.