Offer summary

Qualifications:

High school diploma or GED required, associate's degree preferred., Certifications such as CCDS, CCDS-O, CDIP, RHIA, or RHIT are required., RN or LPN licensure is preferred., At least 1 year of experience in documentation improvement processes is preferred..

Key responsibilities:

Review inpatient medical records to identify documentation gaps.

Collaborate with providers and coding staff to ensure accurate coding and documentation.

Query physicians to clarify diagnoses and ensure proper DRG and risk adjustment.

Educate healthcare providers on coding guidelines and documentation standards.

Job description

Job Details

Job Location: Washington Regional Med. Ctr. - Fayetteville, AR

Position Type: Full Time

Education Level: Certification in related field

Salary Range: Undisclosed

Job Shift: Day

Job Category: Admissions & Billing Services

Description

Organization Overview, Mission, Vision, and Values

Our mission is to improve the health of people in the communities we serve through compassionate, high-quality care, prevention, and wellness education. Washington Regional Medical System is a community-owned, locally governed, non-profit health care system located in Northwest Arkansas in the heart of Fayetteville, which is consistently ranked among the Best Places to live in the country. Our 425-bed medical center has been named the #1 hospital in Arkansas for four consecutive years by U.S. News & World Report. We employ 3,400+ team members and serve the region with over 45 clinic locations, the area’s only Level II trauma center, and five Centers of Excellence - the Washington Regional J.B. Hunt Transport Services Neuroscience Institute; Washington Regional Walker Heart Institute; Washington Regional Women and Infants Center; Washington Regional Total Joint Center; and Washington Regional Pat Walker Center for Seniors.

Position Summary

The role of the Inpatient CDI Specialist reports to the CDI Manager. This position is responsible for ensuring the validity and accuracy of ICD-10 coding and MEAT/ TAMPER criteria are met to facilitate medical necessity and risk adjustment, in compliance with all Federal and State coding regulations and reporting requirements. The CDI specialist works collaboratively with other inpatient and outpatient CDI specialists, coding, physicians/providers, HIM, quality and other key hospital personnel to ensure the electronic medical record is clear and complete.

Essential Position Responsibilities

Performs concurrent reviews of inpatient medical records to identify opportunities to clarify incomplete or conflicting information.
Serves as a liaison between providers and coding staff to ensure the appropriate application of codes and coding guidelines to inpatient medical records.
Clarifies inpatient clinical documentation by querying providers to ensure the appropriateness of the primary and all secondary diagnoses with an emphasis on accurate DRG and risk factor assignment in order to maximize quality, consistency and continuity of patient care.
Provides education to physicians, providers and other internal teams to support above stated objectives.
Remains knowledgeable on current coding regulations to ensure local, state, and federal guidelines are met. This includes compliance with current CDI specialist CEU requirements.

Qualifications

Education: High school diploma or GED, required. Associates degree in a healthcare or business related field, preferred. Graduate of an accredited nursing program, preferred.
Licensure and Certifications: CCDS, CCDS-O, CDIP, RHIA, or RHIT required. RN or LPN, preferred.
Experience: Minimum 1 year previous experience with documentation improvement processes, preferred.

Work Environment: This position will spend 80% of time sitting while performing work in a standard office environment. This position will spend 20% of time standing and/or walking while pushing, pulling, lifting, and/or carrying up to 50 lbs.