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CDI Specialist - Tacoma, WA Area

HIM | Tacoma, WA | Full Time

Job Description

Clinical Documentation Improvement Specialist 

Tacoma, WA Area

Summary

Cooper Thomas, LLC, a leading provider of clinical documentation improvement, medical coding, and auditing services to the Federal Government, has an immediate opening for a full-time, experienced CDI Specialist to support a growing CDI program.  Preference will be given to CDI specialists with DoD MHS coding and MHS software experience.  

Please note that this is an on-site position, which will be performed remotely on a temporary basis. You must be located in the Tacoma, WA area.  All applicants not currently living in the area must relocate, if hired. Applicants must be United States citizens.

Education and Certification

Applicants must have a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) credential through the American Health Information Management Association (AHIMA), or a Certified Professional Coder (CPC) credential through the American Academy of Professional Coders (AAPC).

CDI Specialists must maintain at least one of the following certs from either AHIMA or ACDIS:

  • Clinical Documentation Improvement Practitioner (CDIP)
  • Certified Clinical Documentation Specialist (CCDS)

Applicants must provide proof of certification at the time of application.

In addition, candidates must hold one of the following degrees:

  • Bachelor of Science in Nursing (BSN)
  • Registered Nurse (RN)
  • Physician Assistant (PA)

Candidates must be credentialed/licensed through or have a degree from a school accredited from one of the following organizations:

  • The Comm on Accreditation for Health Informatics and Info Mgmt Education (CAHIIM)
  • Educational Commission for Foreign Medical Graduates (ECFMG)
  • Commission on Graduates of Foreign Nursing Schools (CGFNS)
  • Accreditation Commission for Education in Nursing (ACEN)
  • The Commission on Collegiate Nursing Education (CCNE)
  • The Liaison Committee on Medical Education (LCME)
  • The American Medical Association (AMA)
  • The Commission on Osteopathic College Accreditation (COCA)
  • The American Osteopathic Association (AOA)
  • The Accreditation Review Commission on Education for the Physician Ass’t (ARC-PA)

Experience 

Candidates must have:

  • A minimum of 3-5 years of recent CDI experience in an acute care hospital setting, with at least 2 years of CDI experience in ICD10-CM/PCS and MS-DRGs
  • Experience providing physician and/or CDI education or similar clinical background education.

When applying for the position:

  • Candidates with no DoD experience must provide copies of certificates and a resume evidencing 3 years of CDI experience within the last 5 years.
  • Candidates with DoD experience must provide copies of certificates and a resume evidencing 2 years of CDI experience within the last 5 years.

We are looking for a candidate who has extensive knowledge of:

  • Disease processes, clinical indicators, pharmacology medical terminology and usage, including general medical, surgical, pharmaceutical, hospital terms and abbreviations, and abstracting techniques.
  • Official 10-CM, ICD-10/PCS, CPT, APC, DRG and MHS Coding Guidelines for coding and reporting. Preference will be given to applicants with previous coding experience.
  • Healthcare regulations, including reimbursement and documentation requirements for severity of illness, risk of mortality, quality outcomes, accurate coding, and DRG assignment.

To be successful in this position, the CDI Specialist must be able to:

  • Complete initial medical record reviews of patient records within 24-48 hours of admission for specified patient population to (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnosis, and procedures for accurate DRG assignment, risk of mortality and severity of illness, and (b) initiate a review sheet.
  • Conduct follow-up reviews of patients every 2-3 days to support and assign a working or final DRG assignment upon patient discharge.
  • Meet average productivity of 3.2x-3.5x per hour based upon the expected number of initial and subsequent concurrent reviews each month.
  • Formulate physician queries regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record.
  • Collaborate with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on the topic of documentation and to resolve physician queries prior to discharge.

Specific Duties/Tasks

  • Review and verify component parts of medical record to ensure completeness of documentation requirement and accurate assignment of medical codes for diagnosis, operations, and special therapeutic procedures that must conform to the Official Guidelines for Coding and Reporting, MHS Coding Guidelines. Code primary diagnosis, co-morbidities, complications, therapeutic and diagnostic procedures, supplies, materials, injections, drugs, modifiers, and units of service etc. with ICD-10-CM, CPT, HCPCS, all Evaluation and Management (E/M) levels, and any other coding specific to MHS that may be required by the DOD, including local MTF policy.
  • Identify the correct primary diagnosis, primary procedure, DRGs and POA indicators based on physician's medical record documentation and establish sequencing rules and applicable guidelines. Ensure proper sequencing of ICD-10-CM/PCS codes proper resource for inpatient records and CPT/HCPCS for APV encounters. Identify additional diagnoses/procedures (e.g., complications, co-morbidities, therapeutic procedures, and diagnostic procedures).
  • Analyze and verify the reason for the encounter, including cause(s), primary diagnosis, primary procedure(s), performed and significant related conditions to assure record contents meet the CMS Physician Documentation Guidelines (95 and 97), Joint Commission, and Army regulation requirements for the highest attainable quality.
  • Validate and manage code corrections of the diagnosis, evaluation and management, procedures or any other codes required for the complete and accurate preparation of the Standard Inpatient Data Record (SIDR).
  • When documentation of the medical record is not adequate to identify the appropriate code, query physicians, face-to-face or via clinical documentation inquiry forms regarding missing, unclear or conflicting documentation such as operation/procedure reports to ensure diagnosis, procedure and DRG code assignment.
  • Provide education and feedback to providers and other members of the healthcare team to ensure understanding of documentation guidelines of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG.
  • Train physicians, coders, or ancillary staff on improvement as needed. 

Cooper Thomas, LLC is a leading provider of health information management services. Established in Washington, DC in 2003, Cooper Thomas offers a competitive salary and benefits package, opportunities for quality bonuses, and the opportunity for growth. The selected candidate will be required to undergo a background investigation. Equal opportunity employer.  Veterans encouraged to apply.

IMPORTANT NOTE: To apply, please go to the “Careers” section of our website at www.cooperthomas.com, and follow the instructions to register and apply.