CDI Specialist and Coding Manager

Adirondack Health – Saranac Lake, NY

Position Summary:

The role of this position is that of an educator and a coding manager. The candidate must possess exceptional interpersonal skills and current subject matter expertise to successfully and pro-actively work with all members of the healthcare team and oversee all types of coding services including Inpatient, Ambulatory Surgery, Emergency, Outpatient, Specialty Clinics and Primary Care. Education needs may be identified through focused and random monitoring, data analysis and coder or provider feedback or interest for daily concurrent review of inpatient medical records to identify opportunities for improving the quality of medical record documentation for reimbursement, severity of illness, and risk of mortality. This work is accomplished in consultation with the HIM Director, coding staff and others as appropriate following AHA Coding Clinic and all other reference sources published by the Association of Clinical Documentation Improvement Specialists (ACDIS) and the American Health Information Management Association (AHIMA) and helps to design and develop computer application systems to query providers, collect statistics from the reviews and maintain accurate records of review activities, to document cost/benefits and to identify patterns and trends affecting the case mix index. The goal is to achieve a complete medical record by the time of patient discharge in order to facilitate the coding and DRG assignment process. Determines outpatient clinical documentation improvement opportunities through ongoing internal monitoring and data analysis. Recommend and implement methods for addressing the areas that are identified Identifies cases where diagnoses, procedures and/or charge codes are either absent, not stated in appropriate terminology, or are not appropriately recorded. The outcome is a medical record that is as accurate and complete as possible prior to discharge from inpatient or outpatient services. All services provided are billed and abstracted based on supporting documentation in the medical record.Manages a staff of 12 coders. Assigns work, evaluates productivity and manages workflow including the discharged not final billed report. Provides education and educational opportunities for the staff to ensure they are kept current with the changing regulatory landscape of coding and billing.with the revenue cycle team on appeals. Evaluates the denial trends and assists with corporate compliance auditing work.

Educational Requirements/ Qualifications:

Education: RHIA or RHIT with a Bachelors degree in healthcare field preferred and CCS Certification required.



Experience: Previous CDI experience in an acute care setting required. Management experience preferred. Experience with outpatient and ambulatory surgery coding and experience with electronic medical records is required. Experience with 3-M Coding and reimbursement programs a plus and will be required within 3 months of hire. Experience with MS-Office suite, Excel and PowerPoint expertise in particular required.


Skills: Demonstrates excellent interpersonal skills to develop relationships necessary to effectively influence physician/clinical documentation accuracy and timeliness in a positive and pro-active manner. Demonstrates analytic skills necessary to clinically assess medical records in the context of prevailing coding standards and regulations. Demonstrates excellent prioritization and organizational skills. Demonstrates outstanding public speaking and formal presentation skills; and the ability to successfully provide education to a wide variety of
adult learners. Demonstrates Intellectual curiosity and willingness to accept feedback in a positive manner. Demonstrates flexibility to adapt to challenging work situations and varied styles. Demonstrates ability to consistently and effectively work under pressure while meeting compliance targets and maintaining positive demeanour.

Knowledge: Current working knowledge of published ACDIS and AHIMA Clinical Documentation Improvement practices, guidelines and metrics required. Current working knowledge of ICD-10 coding principles and guidelines. Current working knowledge of MS-DRGs and APR-DRGs. Working knowledge of CPT and HCPCS coding. Working knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation, coding, and reimbursement required.

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