Position#Summary: The UR/CDI Specialist gathers clinical information, certifies medical necessity, maintains an organizational wide system for improving accuracy of clinical documentation, assigns appropriate length of stay, and works with various insurance companies on a prospective, concurrent, and retrospective basis for in-patient admission and outpatient services. Communicates with the discharge planning team to assist in facilitating a smooth and effective transition to the next level of care.
Performs utilization activities, using Milliman Care Guidelines under the guidance of the Physician Advisor, to provide clinical information to payors as requested and ensures correct status of all patients to insure maximum reimbursement. Works with medical and clinical staff to improve overall quality and completeness of clinical documentation.
Communicates and educates medical, clinical and coding staff of trends and opportunities for improvement. Tracks and trends all queries presented to medical and clinical staff. Follows department policies to remain in compliance with State and Federal regulations. Other duties as assigned
Required: Billing/Coding Certificate,#or Associates/Diploma Degree in Practical Nursing, or Registered Health Information Technologist or other related clinical degree.
Preferred: Bachelor#s degree in healthcare or other related area. Minimum Years of Experience
Required: Three years of Inpatient Coding or Utilization Review experience or direct patient care experience as clinical care provider.
Preferred: Five years of Inpatient Coding or Utilization Review experience or#direct patient care experience as clinical care provider. License, Registry or Certification
Required: Certified Clinical Documentation Improvement Specialist or Registered Health Information Administrator or Certified Coding Specialist Certification or related coding or#auditing#certification.# All#staff#to be Certified Clinical Documentation Improvement Specialist within two and#half years from start date in position. Preferred: Certified Clinical Documentation Improvement Specialist Knowledge, Skills and/or Abilities
Required: Excellent verbal, written, organizational and interpersonal skills.
Demonstrates experience in patient care evaluation methodologies, analysis and reporting of patient clinical data to various payee sources using Miliman Care Guideline criteria sets. Preferred: None