The Clinical Documentation Integrity (CDI) Specialist is accountable for reviewing patient medical records in the inpatient and/or outpatient setting to capture accurate representation of the severity of illness and facilitate proper coding. The CDI Specialist validates that coding reflects medical necessity of services and facilitates appropriate coding which provides an accurate reflection and reporting of the severity of the patient's illness along with expected risk of mortality and complexity of care. Documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care. Utilizes advanced knowledge of disease processes (pathophysiology), medications, and have critical thinking skills to analyze current documentation to identify gaps. Identifies opportunities in concurrent and retrospective inpatient clinical medical documentation to support quality and effective coding. Understands and applies regulatory compliance related to documentation, coding and billing for all health insurance plans. The CDI Specialist facilitates appropriate modifications to documentation through extensive interactions and collaboration with physicians, coding, case management, nursing and other care givers. Serves as an effective change agent as an educator and resource for physicians and allied health staff to improve the quality and completeness of the clinical documentation. Performs all duties and responsibilities in accordance with ethical and legal business procedures, compliant with federal and state statutes and regulations, official coding rules, guidelines and accepted standards of coding practice including appropriate clinical documentation policies.
Entry-level or minimal experience in a Clinical Documentation Integrity Specialist (CDIS) role and must have the Certified Clinical Documentation Specialist (CCDS) or the Certified Documentation Improvement Practitioner (CDIP) certification] and: Any of the following: Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician-based (CCS-P), Registered Nurse (RN), completion of international or domestic medical program or, Formal education (accredited college-level course work) in human anatomy and physiology, medical terminology, and disease process or, Associate's degree or higher (candidates must also have completed coursework in medical terminology and anatomy and physiology.
Bachelor of Science-Nursing (BSN) or Registered Health Information Administrator (RHIA). Demonstrated skills in analytical thinking, problem solving. Effective verbal and written communication including ability to present ideas and concepts effectively to physicians, management and other members of our healthcare team. Self-motivated and able to work independently without close supervision. Demonstrated ability to work well with others in a creative and challenging work environment. Must be able to work flexible hours which may include evenings and weekends as required to meet business needs.
License or certification
Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist-Physician-based (CCS-P), Associated Degree Nurse (ADN-RN), completion of international or domestic medical program or, Formal education (accredited college-level course work) in human anatomy and physiology, medical terminology, and disease process or, an Associate's degree or higher (candidates must also have completed coursework in medical terminology and anatomy and physiology) and, Certified Documentation Improvement Practitioner (CDIP) certification or Certified Clinical Documentation Specialist (CCDS) certification.
Education, experience and tenure may be considered along with internal equity when job offers are extended. The minimum salary every 2 weeks is approx $2,569.60, based on a full-time position.
Mayo Clinic is located in the heart of downtown Rochester, Minnesota, a vibrant, friendly city that provides a highly livable environment for more than 34,000 Mayo staff and students. The city is consistently ranked among the best places to live in the United States because of its affordable cost of living, healthy lifestyle, excellent school systems and exceptionally high quality of life.
Other Patient Care
Job posting number
Equal opportunity employer
Mayo Clinic is an equal opportunity educator and employer (including veterans and persons with disabilities).