Clinical Documentation Improvement (CDI) Specialist I Alta Hospitals System

About the Role

In this role as a Clinical Documentation Improvement (CDI) Specialist, you will be responsible for reviewing and improving the accuracy and completeness of patient medical records in an acute care hospital setting. This involves working closely with physicians and other healthcare professionals to ensure that documentation meets regulatory and accreditation standards. You will also be responsible for identifying and addressing any discrepancies or inconsistencies in patient records.

Key Responsibilities

• Review and analyze patient medical records for accuracy and completeness, identifying areas for improvement and implementing changes as needed.
• Collaborate with physicians and other healthcare professionals to resolve queries and discrepancies in patient records, ensuring that documentation meets regulatory and accreditation standards.
• Develop and maintain knowledge of regulatory requirements, including HIPAA, and ensure that patient records are compliant with these standards.
• Provide excellent customer service to patients, families, and healthcare professionals, responding to inquiries and concerns in a timely and professional manner.
• Stay up-to-date with industry developments and best practices in clinical documentation improvement, applying this knowledge to improve patient care and outcomes.
• Participate in quality improvement initiatives and projects, contributing to the development and implementation of policies and procedures related to clinical documentation improvement.
• Communicate effectively with healthcare teams, including physicians, nurses, and other staff members, to ensure that patient records are accurate and complete.

Skills & Qualifications

• Bachelor's degree in a healthcare-related field, such as health information management or nursing.
• Experience working in a healthcare setting, preferably in a clinical documentation improvement role.
• Strong knowledge of medical records, including HIPAA regulations and industry standards.
• Excellent verbal and written communication skills, with the ability to communicate effectively with healthcare professionals and patients.
• Proficiency in computer software and systems, including electronic health records (EHRs) and medical coding systems.
• Certification in clinical documentation improvement, such as the Certified Clinical Documentation Specialist (CCDS) credential.
• Ability to work in a fast-paced environment, prioritizing tasks and managing multiple projects simultaneously.

What You'll Learn

In this role, you will have the opportunity to develop and refine your skills in clinical documentation improvement, including reviewing and analyzing patient medical records, collaborating with healthcare professionals, and staying up-to-date with industry developments and best practices. You will also learn about regulatory requirements, including HIPAA, and how to apply this knowledge to improve patient care and outcomes.

Resume Tip

When applying for this role, be sure to highlight your experience working in a healthcare setting, particularly in a clinical documentation improvement role. Emphasize your knowledge of medical records, including HIPAA regulations and industry standards, as well as your excellent verbal and written communication skills. Additionally, be sure to mention any relevant certifications, such as the Certified Clinical Documentation Specialist (CCDS) credential.