Job Description

Job Title: Clinical Documentation Improvement (CDI) Specialist
Job ID: 20654147
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility:
Department: Rev Cyc Coding
Location: 2 Hot Metal Street, Pittsburgh PA 15203

Description

Purpose:
The Clinical Documentation Specialist (CDS) facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of services rendered to all inpatients.

This is a full time, remote role.  It is scheduled Monday through Friday during flexible daylight hours.

Responsibilities:
  • Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team
  • Communicate with physicians, face-to-face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
  • Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team
  • Participating at the organizational level in clinical documentation improvement initiatives
  • Preparing trended data for presentation one-on-one and small to medium groups of physicians
  • Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans

Qualifications

  • Three years of previous clinical acute care nursing experience medical/surgical experience to include critical care in conjunction with an expanded knowledge of DRGs; 
    • OR completion of Health Records Administration program (RHIA) or Accredited Record Technician (RHIT) AND three years of experience with the Prospective Payment System and DRG selection; 
    • OR specific knowledge as a consultant in Medical Record coding and DRG assignment required. 
  • Prior CDI work experience preferred. 
  • Knowledge of computer technology, quality assurance activities, DRG, Quality Insights/Utilization review background is highly preferred. 
  • Ability to communicate with staff, physicians, healthcare providers, and other health care system personnel in a professional and diplomatic manner required.

Licensure, Certifications, and Clearances:
  • Certified Coding Specialist or Certified Registered Nurse Practitioner or Doctor of Podiatric Medicine or Medical Doctor or Registered Health Information Administrator or Registered Health Information Technician or Registered Nurse

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $24.99 to $43.25 / hour

Union Position: No

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