Coding - CDI Specialist - (FT)

Summary

Madisonhealth is seeking a Clinical Documentation Integrity (CDI) Specialist. This position works across the hospital organization to strengthen the accuracy, completeness, and quality of the clinical documentation in the patient medical record. The primary purpose of this position is to review clinical documentation concurrently and retrospectively, identify gaps or ambiguity in provider documentation, and initiate compliant queries to providers to support accurate severity of illness, risk of mortality, and DRG/code assignment. This position works closely with the Coding and HIM departments to educate providers on documentation best practices and to close the gap between clinical care rendered and what is captured in the record.

Classification: Full Time

Schedule:

• Mon-Fri
• 8:00am-5:00pm
• Hybrid: Must live within daily driving distance

Required Skills

• Knowledge of ICD-10-CM/PCS coding guidelines and their relationship to DRG assignment, severity of illness (SOI), and risk of mortality (ROM).
• Strong knowledge of medical terminology, anatomy and physiology, disease processes, and pharmacology sufficient to interpret complex chart/office notes.
• Ability to formulate clear, compliant, non-leading provider queries in accordance with AHIMA/ACDIS query practice guidance.
• Knowledge of Cerner and CDI/3m encoder software as applicable.
• Knowledge of Microsoft Outlook, Word, Microsoft Excel and Windows.
• Strong interpersonal and communication skills; ability to build collaborative relationships with physicians, advanced practice providers, coding staff, and quality/UR teams.
• Positive attitude and superior customer service.
• CCDS (ACDIS) Certified Clinical Documentation Specialist, CDIP (AHIMA) Certified Documentation Integrity Practitioner, or CDEI (AAPC) Certified Documentation Expert Inpatient required.

Minimum Work Experience:

• Minimum of 2 years of clinical experience (e.g., RN, coding, or related clinical background) or equivalent combination of clinical documentation integrity experience and education.

Minimum Education:

• Associate or Bachelor's degree in Nursing, Medical Coding, Chart Analysis Review, or related field preferred; equivalent work experience will be considered.

Benefits & Work-Life

We not only offer comprehensive benefits and work-life programs to secure your future and balance your daily needs but also provide you stellar service for managing these programs through our Benefits Department.

Retirement - Securing your future

• Retirement - 457(b)
• Hospital Pension Plan - 401(a)

Health Benefits - Safe and Secure, Our Promise

• Health Insurance
• Dental and Vision Insurance
• Flexible Spending Account
• Life Insurance
• Supplemental Plans
• 340B Pharmacy Program
• Madisonhealth Services Discount

Paid Time Off

• Regular Part Time - 3.69 hrs per pay period
• Full Time - 6.77 hrs per pay period
• Long Term Sick - percentage of hrs worked

Work-Life Balance - Employee Assistance Program offers:

• Personal counseling (in-person and virtual)
• Life management services (child and senior care, moving, pets, home repair, disaster support, discounts, etc.)
• Senior care management
• Child care referral services
• Lifestyle coaching
• Health and wellness resources
• Legal & financial services
• Support tools for managers
• Onsite and virtual trainings
• Critical Incident Stress Management services when tragedy happens

Job Description

Madisonhealth is seeking a Clinical Documentation Integrity (CDI) Specialist. This position works across the hospital organization to strengthen the accuracy, completeness, and quality of the clinical documentation in the patient medical record. The primary purpose of this position is to review clinical documentation concurrently and retrospectively, identify gaps or ambiguity in provider documentation, and initiate compliant queries to providers to support accurate severity of illness, risk of mortality, and DRG/code assignment. This position works closely with the Coding and HIM departments to educate providers on documentation best practices and to close the gap between clinical care rendered and what is captured in the record.

Classification: Full Time

Schedule:

• Mon-Fri
• 8:00am-5:00pm
• Hybrid: Must live within daily driving distance

Required Skills

• Knowledge of ICD-10-CM/PCS coding guidelines and their relationship to DRG assignment, severity of illness (SOI), and risk of mortality (ROM).
• Strong knowledge of medical terminology, anatomy and physiology, disease processes, and pharmacology sufficient to interpret complex chart/office notes.
• Ability to formulate clear, compliant, non-leading provider queries in accordance with AHIMA/ACDIS query practice guidance.
• Knowledge of Cerner and CDI/3m encoder software as applicable.
• Knowledge of Microsoft Outlook, Word, Microsoft Excel and Windows.
• Strong interpersonal and communication skills; ability to build collaborative relationships with physicians, advanced practice providers, coding staff, and quality/UR teams.
• Positive attitude and superior customer service.
• CCDS (ACDIS) Certified Clinical Documentation Specialist, CDIP (AHIMA) Certified Documentation Integrity Practitioner, or CDEI (AAPC) Certified Documentation Expert Inpatient required.

Minimum Work Experience:

• Minimum of 2 years of clinical experience (e.g., RN, coding, or related clinical background) or equivalent combination of clinical documentation integrity experience and education.

Minimum Education:

• Associate or Bachelor's degree in Nursing, Medical Coding, Chart Analysis Review, or related field preferred; equivalent work experience will be considered.

Benefits & Work-Life

We not only offer comprehensive benefits and work-life programs to secure your future and balance your daily needs but also provide you stellar service for managing these programs through our Benefits Department.

Retirement - Securing your future

• Retirement - 457(b)
• Hospital Pension Plan - 401(a)

Health Benefits - Safe and Secure, Our Promise

• Health Insurance
• Dental and Vision Insurance
• Flexible Spending Account
• Life Insurance
• Supplemental Plans
• 340B Pharmacy Program
• Madisonhealth Services Discount

Paid Time Off

• Regular Part Time - 3.69 hrs per pay period
• Full Time - 6.77 hrs per pay period
• Long Term Sick - percentage of hrs worked

Work-Life Balance - Employee Assistance Program offers:

• Personal counseling (in-person and virtual)
• Life management services (child and senior care, moving, pets, home repair, disaster support, discounts, etc.)
• Senior care management
• Child care referral services
• Lifestyle coaching
• Health and wellness resources
• Legal & financial services
• Support tools for managers
• Onsite and virtual trainings
• Critical Incident Stress Management services when tragedy happens