Post-Acute IRF Clinical Documentation Integrity Specialist CDI
Health Information Management
The Post-Acute Clinical Documentation Integrity Specialist is responsible for facilitating the improvement in the overall quality and completeness of clinical documentation to support coding in the post-acute inpatient setting, and will be responsible for reviewing daily new admission inpatient post-acute medical records, as well as, subsequent reviews while patient is still in-house (concurrent) until discharged. The Specialist is also responsible for querying physicians on specificity of diagnosis or procedures performed in order to ensure the account appropriately reflects the patient's acuity and resources used to care for the patient resulting in complete and accurate profiling and reporting outcomes. In addition, the Specialist will provide documentation and coding education as needed.
- Require a Bachelor's degree (preferably BSN). Associate degree in Nursing (ASN) and two (2) years of relevant work experience in an acute or post-acute setting can substitute for the required degree.
- Require a minimum of three (3) years of clinical experience in the area of hire (CDIS, SNF, IRF, or LTCH).
- Require an active Florida Registered Nurse (RN) license or Medical Doctor (MD) equivalent.
- Prefer the ability to communicate verbally and in writing.
- Prefer the ability to multi-task, shift priorities, and demonstrate decision-making ability.
- Prefer the ability to work independently and collaboratively in a team environment.
- Prefer certification as Certified Documentation Improvement Professional (CDIP) or Certified Clinical Documentation Specialist (CCDS).
- Prefer Certified Rehabilitation Registered Nurse (CRRN) Certification.
- Prefer knowledge of Prospective Payment System methodology in area of hire (Skilled Nursing Facility Prospective Payment System - Patient Driven Payment Model (PDPM); Inpatient Rehabilitation Facility - Case Mix Group (CMG); Long Term Care Hospital - MS-LTC-DRG).
- Prefer proficiency in Adobe Acrobat and Microsoft Office suite, specifically Excel, PowerPoint, and Word.
Required License and Certs
Preferred License and Certs