Description

POSITION SUMMARY:
The Clinical Documentation Improvement (CDI) Specialist is responsible for facilitating the improvement in the 
overall quality and completeness of provider-based clinical documentation in the medical record. This position 
will be responsible for assisting treating providers to ensure that documentation in the medical record accurately 
reflects the severity of the illness of the patient as well as the level of services rendered. 

JOB ESSENTIAL DUTIES:
Facilitates appropriate clinical documentation to support appropriate diagnosis coding and to ensure the 
level of service rendered to all patients is recorded

• Review and audit patient charts in the EHR for the clinical status of the patient, current treatment plan, past 
  medical history, quality measures (e.g., HEDIS, HCC, etc..), and identify potential gaps in provider 
  documentation.
• Applies clinical knowledge and expertise to accomplish optimal identification of patient’s condition in the 
  medical record.
• Communicates with providers to validate observations for more specific documentation and/or diagnoses 
  via concurrent query process guidelines to reflect treatment, decision-making, and medical documentation
  Collaborates with physicians and coding staff to promote complete and accurate clinical documentation 
  and correct negative trends.
• Formulates credible clinical documentation clarifications to improve clinical documentation of principal 
  diagnosis, co-morbidities, and quality core measures.
• Conducts post-visit reviews for comparative analysis of CDI process
  Develops and conducts ongoing education for new staff, including new CDI Specialists, physicians, and 
  nursing.
• Ability to work at the Population Health Events during the work week and on some Saturdays
  Utilizes software systems (e.g., Athena, ENLI) to collect, track, and report outcomes.
• Abstracts and completes data entry into all databases used for clinical documentation
  Maintains integrity of data collection.
• Participates in the ongoing education of staff related to the scope of the role.
• Develops educational material and tools to support documentation improvement practices for individual 
  practitioners and groups of clinicians.
• Maintains an open line of communication with the leadership team on the status of MCR Health operations 
  and key performance indicators as it relates to areas of assigned responsibility
  Obtains and maintains any identified certifications.
• Promotes the concept of Providing an Exceptional Experience to Everyone, Every Time.
• Completes day-to-day tasks to assure the smooth operation of MCR Health
  Supports the mission and vision of MCR Health.
• Adheres to all MCR Health policies, procedures, and standards.
• Performs other duties as assigned

SKILLS, KNOWLEDGE & ABILITIES:

• Excellent listening and interpersonal skills
• Excellent oral and written communication
• Critical/Strategic thinking
• Tech savvy and systems thinking
• Ability to receive and act upon feedback in a calm, professional manner
• Ability to multi-task and prioritize tasks, projects, and demands
• Ability to work collaboratively with others
• Customer service focus to impact the patient experience
• Ability to connect with patients/others and help them feel at ease
• Ability to effectively interact with customers, staff, and others even in stressful situations
• Comfortable and adept with technology
• Ability to maintain confidence and demonstrate discretion

Requirements

REQUIREMENTS & PREFERENCES:

• Bachelor's degree in the healthcare-related field required
• Required certification or license must be one of the following:
• Registered or Licensed Practical Nurse
• Certified Coder (AAPC or AHIMA preferred)
  MD equivalent
• AHIMA Clinical Documentation Improvement Practitioner (CDIP) certification
• 1+ years' experience in population health required (3+ preferred)
• 1+ years' experience working in a healthcare setting required (3+ in outpatient ambulatory setting 
  preferred)
• 1+ years' experience with abstracting and data entry related to clinical documentation
  Proficient in Microsoft Office Suite required
• Valid driver's license required
• Ability to move between sites as needed (with mileage reimbursement)
• Bilingual (Spanish/English) a plus