CDI Specialist Job Description
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Clinical documentation improvement specialists perform concurrent reviews of patient health records to ensure complete, accurate, and specific clinical documentation. They have a comprehensive understanding of CMS Coding Guidelines and are responsible for clarifying conflicting, incomplete, or imprecise documentation by actively seeking answers and educating active providers.
Their daily routines probably include the following responsibilities:
Reviewing overall quality and completeness of clinical documentation.
Reviewing patient records with an emphasis on improving documentation.
Applying comprehensive knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures to ensure proper code selection.
Adhering to accepted coding practices, guidelines, and conventions.
Assisting facility staff with documentation requirements to completely and accurately reflect the patient care provided.
Inpatient clinical documentation improvement specialists are often onsite as they complete concurrent reviews. This allows them to have real-time dialog with the provider as they review patient charts and records. Remote work is becoming more common for this role, however that would depend upon the individual needs of the organization.
As this career path is a level above standard medical coding roles, the salary potential is pretty significant. According to Burning Glass, the average salary for Learners in this career is $68,340.