Clinical Document Specialist - CDI
Job Description
Key Skills
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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
Note: Myglit doesn't charge any money from candidates. If you have been asked to pay money to get this job then report to us immediately at support@myglit.com.
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- Giving the VNA round?
- What are the most important skills you acquired as a Soft Skills/VNA trainer?
- How would you handle an irate customer?
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