Location: Maryland, MD
Cap-Exempt H-1B Position — No lottery required
About this Job: **General Summary of Position** Ensures that documentation supports accurate complete and consistent unambiguous clinical documentation. Utilizes clinical expertise to support appropriate reflection of the patient's risk of mortality and severity of illness. Develops compliant physician queries guided by the American Health Information Management Associations (AHIMA) Ethical Standards for Clinical Documentation Improvement Professionals the ACDIS/AHIMA Query practice brief and state federal and other appropriate regulatory guidance. Evaluates the medical records for case specific review including mortalities complications quality of care and other needs identified requiring review and/or second level review. Reviews and analyzes inpatient record for compliant documentation. Provides education to all levels of clinical staff. Closely collaborates with coding professionals to ensure appropriate ICD-10 and DRG assignment. Maintains certification and credentials applicable to the Clinical Documentation Integrity Specialist role. Monitors clinical case data to identify areas of improvement. **Primary Duties and Responsibilities** - Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations. - Demonstrates a cooperative collaborative and team-oriented approach with CDI team coders nursing staff medical staff and all other ancillary departments. Communicates effectively to ensure a coordinated standardized and effective approach with clinicians. - Demonstrates the appropriate utilization of paper and electronic CDI chart review resources to foster transition of cases within the CDI team. Ensures the CDI work sheet includes precise clinical details appropriate data entry into software and complete and updated code set to support physician queries and support case review decisions. - Develops written