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Job Title Location Date
Clinical Documentation Improvement Specialist Springfield, IL Jun 14
Requirements
Maxim Health Information Services (MHIS) is seeking Clinical Documentation Improvement (CDI) Specialists to serve as Interim CDI Specialist in hospitals throughout the US. These positions are travel positions.

The responsibilities are primarily to review medical records concurrently within the requesting facilities and determine if there are gaps in documentation; if so, query the physicians appropriately to clarify the documentation to support and then record the appropriate working MS-DRGs. As part of the interview process, candidates for the CDI Specialist positions will be interviewed by Maxim’s account executives and Director of CDI, as well as the client if they so desire. A CDI-focused set of questions will be provided to determine depth of CDI capabilities and familiarity of the CDI process. Depending on the candidate’s background, knowledge / depth of CDI experience and basic interview result and Maxim’s capability, candidates may be mentored prior to being placed on a client site.

Basic CDI Program understanding:
Depending on the client environment and current CDI methodology, the CDI program’s basic understanding and objective is to facilitate communication and collaboration among client identified coders, physicians, utilization nurses and MHIS clients in order to identify documentation opportunities and then acquire complete clinical information in the medical record enabling HIM to reflect accurate code and MS-DRG assignments, as well as appropriate severity of illness, risk of mortality, POA code, and RAC required documentation. By focusing on these efforts and striving to eliminate documentation gaps, the CDI Program will provide clients with accurate and compliant documentation resulting in appropriate healthcare facility reimbursement.

Job Requirements:
Two types of credentials are acceptable:
-HIM professional candidates must be credentialed as an RHIA, RHIT, CCS and have experience in ICD-9CM hospital based coding. HIM management experience is a plus.
-Clinical candidates must be credentialed as an MD, PA, RN, BSN, (C-CDIS is a plus). Strong clinical background for a minimum of three years in Med-Surg, ICU or Surgery experience is a must.

For both HIM and Nursing candidates - optional but a large plus:
-Case Management / Utilization review experience
-Clinical Documentation Specialist Hospital experience
-Certification as a Certified Documentation Improvement Specialist
-Worked as a CDI Consultant
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