Job Description
Job Summary:
The Clinical Documentation Integrity Specialist (CDIS) provides clinically based, concurrent and retrospective reviews of inpatient medical records. CDI strives to ensure accurate, complete, compliant, concise, and consistent documentation that reflects the true clinical scenario of the patient's encounter. This additionally serves to reflect the true Severity of Illness (SOI), Risk of Mortality (ROM), and Intensity of Services (IOS) rendered to provide quality care and treatment to the patient. The Clinical Documentation Integrity Specialist serves as a liaison between leadership, medical staff, nursing, coding, case management and quality departments. Excellent communication skills and the ability to critically analyze are essential to successful CDI performance. This is an intermediate level position for experienced and proficient CDI Specialists.
REQUIRED KNOWLEDGE & SKILLS :
- Must possess strong organizational, communication and clinical foundation skills.
- Must demonstrate proficiency in EMR software, CDI applications (after education and orientation) and Microsoft applications.
- Demonstrates ability to multi-task and work efficiently and effectively between software platforms.
- Demonstrates the ability to communicate effectively in a fast-paced environment with multidisciplinary teams consisting of physicians, nurses, coders, administration, and other health care professionals.
- Demonstrates proficiency in CDI process after completion of onboarding and orientation/education. Continued improvement in proficiency and accuracy is expected during and after orientation/onboarding.
- Experienced CDI Specialists are expected to onboard more quickly and perform commensurate with experience level.
- Ability to work independently, prioritize tasks and demonstrate self-awareness in the workplace.
- Always maintains confidentiality and HIPAA compliance.
EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:
I. Education: Bachelor's degree in a clinical or coding study is preferred. Advanced degrees such as Master, Doctorate or Foreign Medical Graduate will require proof of degree status.
II. Experience: Minimum of 2-5 years acute clinical or coding (IP) experience preferred. A minimum of 1 or more years CDI experience required with proficiency consistently demonstrated.
III. Licensure/Certification: RN or LVN with current state license, proof of certification when applicable IV. Software/Hardware: Proficiency in Microsoft applications, EMR applications, CDI, and coding software
What Should I Know About Hialeah Hospital?
Our 378-bed acute care hospital opened in 1951 to serve the Hialeah, Florida community. Our team is committed to honoring the trust that our patients place in us by providing compassionate, safe, high-quality care in the right place, and at the right time.
Hialeah Hospital has been honored to receive a number of awards and designations for our superior health care services, including:
Cardiac
American Heart Association Get with the Guidelines - Heart Failure Gold Plus Award, 2018
American Heart Association Get with the Guidelines - Target Stroke Gold Plus Award, 2018
Bariatric
American College of Surgeons/American Society for Metabolic and Bariatric Surgery - MBSAQIP Accredited Center
BCBS - Blue Distinction Specialty Care Bariatric Surgery, January 2018
Neurology
Advanced Primary Stroke Center Re-accreditation, April 2018
Women's Services
American College of Radiology granted Stereotactic Breast Biopsy Re-accreditation, March 2016
Hyperbaric Unit
Healogics Center of Distinction Award, 2017
Laboratory Services/Blood Bank
Certificate of Accreditation from College of American Pathologist
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