Clinical Documentation Improvement Specialist II

Assists with the appropriate identification of diagnoses, conditions, and/or procedures that are representative of the patient’s hospital stay and care provided including Severity of Illness (SOI), Risk of Morality (ROM), during an inpatient hospitalization. CDI Specialist II initiates concurrent queries to providers as supported by medical record documentation to improve the accuracy, integrity, and quality of patient data, and drive improvement toward quality physician documentation within the body of the medical record. Concurrently reviews inpatient records to ensure completeness, accuracy, and clinical validation. Evaluates documentation for assignment of working and possible DRG. Recognizes opportunities for documentation improvement, including severity of illness, risk of mortality, core measures, and patient safety/quality. Identify opportunities to query physicians regarding missing, unclear, or conflicting documentation. Interacts directly with physicians to request and obtain additional documentation when needed. Timely follow-up on all unanswered queries based on the query escalation policy.