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CDI Specialist (Part Time), Ovation

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The Clinical Documentation Specialist (CDS) facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of services rendered to all inpatients.


  • Communicate with physicians, face-to-face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness, may also interact with nurses, case managers and coders
  • Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team
  • May perform retrospective reviews to determine trends/opportunities
  • Participating at the organizational level in clinical documentation improvement initiatives
  • Preparing trended data for presentation one-on-one and small to medium groups of physicians
  • Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans, supporting patient�s SOI, risk of mortality in compliance with all guidelines and requirements
  • Provides training and education as needed
  • Responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team
  • Utilizes ACDIS and other reputable CDI sources to insure best practices


Extensive knowledge of ICD-10-CM/PCS classifications and coding of diagnoses and procedures is required. In depth knowledge of medical terminology, human anatomy/physiology, pharmacology, and pathology is required. RN license + 3 years clinical and CDI experience required AND CCDS or CDIP certification OR Coder with 5 years Inpatient coding experience, 3 years CDI experience with CCS, CIC, RHIA, RHIT AND CCDS or CDIP (2 certifications required - Coding and CDI) The ability to problem solve and to communicate in a professional manner with staff and other health care professionals is essential. Prior CDI work experience preferred. Knowledge of computer technology, quality assurance activities, DRG, Utilization review highly preferred Ability to communicate with staff, physicians, healthcare providers, and other health care system personnel in a professional and diplomatic manner required. Detail oriented individual with excellent organizational skills. High degree of oral and written communication skills. Traveling may be required as necessary. Graduate of an approved Health Record Administration or Accredited Medical Record Technician program (RHIA/RHIT or eligible) or a certified coding program or 3 years clinical acute care nursing experience medical/surgical to include critical care in conjunction with expanding knowledge of DRGs. 3 years relevant experience - preferably 3 years of auditing experience or clinical acute care nursing experience with expanded knowledge of DRGs.

Licensure, Certifications, and Clearances:

  • Certification in Infection Control
  • Certified Cardiac Device Specialist
  • Certified Coding Specialist
  • Certified Documentation Improvement Practitioner
  • Certified Registered Nurse Practitioner or Registered Health Information Administrator or Registered Health Information Technician or Registered Nurse

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Location: Pittsburgh, PA, United States
Job ID: 678173

UPMC is an equal opportunity employer.
Minority / Females / Veterans / Individuals with Disabilities