Clinical Document Specialist - CDI

Gratitude Inc

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1 month ago

Clinical Document Specialist - CDI

2-15 Year(s)

Manila (Taguig)

Job Description

Key Skills

Clinical research Clinical work clinical experience CDI

3 candidate(s) have already applied for this Job. Apply now

Job Title - CDI Specialist Position: CDI specialist.

Location - BGC, Taguig.

Job Type - Permanent

Shifts - Rotational

Eligibility ; Medical Graduates with atleast 2 years of clinical experience in hospital setting with extensive clinical knowledge and understanding of pathology/physiology.

• 1+ year has been in CDI and obtained at least one certification.

Responsibilities

• Conducts initial and follow-up concurrent reviews on targeted admissions for opportunities

to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care.

• Coordinates with coding/HIM/UR and other departments to achieve a record that reflects

the acuity of the patient and level of care provided.

• Review medical record concurrently for documentation not yet in the record but supported by clinical indicators. Performs a thorough chart review to identify co-morbidities/complications, and documents these appropriately within the concurrent CDS worksheet. Determines the appropriate principal diagnosis of the patient.

• Demonstrates an understanding of the importance of, and tries to capture, all appropriate

secondary diagnoses for quality rating purposes.

• Documents findings in workflow tools, noting all key information used in the tracking

process.

• Uses relationship building and strong communication skills to develop a rapport with

providers to clarify information in the medical record.

• Uses appropriate querying tools (templates) to capture needed documentation.

• Queries the medical staff, when necessary, by written and/or verbal communication to

obtain accurate and complete physician documentation that supports the patient

condition(s) and treatment plan.

• Provides education to physicians on the importance of complete documentation and key

documentation concepts during regular physician meetings or individually with physicians.

• Reviews the progress of the CDI program by interpreting performance, process, and quality

ratings reports. Able to identify areas of focus through report analysis.

• Maintains reasonably regular, punctual attendance consistent with Health policies, the

ADA, FMLA and other federal, state

and local standards. Maintains compliance with all Health policies and procedures.

Qualification:

• Expanding on the CDI I role to include reporting and data analysis and creation of service

line dashboards.

• It includes additional focus on provider interaction during rounds and educational sessions,

and creation of educational content for several assigned service lines, incorporating the

clinical units that house the majority of the patients these service lines follow.

• The CDI II is responsible for ensuring efficiency and productivity of the processes and

workflows of his or her team, participating in orientation of new staff, reporting any issues to

the CDI III or leadership, and potentially getting involved in committees/projects.

• Educational Qualifications: Medical Graduate/Doctor, MD or RN,BSN,APRN.

Desired Skill set:

• 7+ years of clinical experience in hospital setting with extensive clinical knowledge and

understanding of pathology/physiology.

• 1+ year has been in CDI and obtained at least one certification.

• Knowledge of age-specific patient needs and the elements of disease processes and

related procedures.

• Excellent written and verbal communication skills; ability to write concisely and effectively

when communicating with providers.

• Certifications that CDI Level 2 can obtain either CCS or CDIP which are both with Ahima.

Has coding knowledge.

Role

Clinical Research

Timings

Rotational Shifts (Permanent)

Industry

BPO

Work Mode

Work from office

Functional Area

Medical Professional / Healthcare Practitioner / Technician

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