Clinical Documentation Improvement (CDI) Physician Advisor

Avenues Resources Consultants

Job Title - Clinical Documentation Improvement Physician Advisor.

Job Family - Administrative.

Reporting to - Director, Health Information Management.

EDUCATION : Bachelor Degree in Medicine, MBBS or Equivalent from an Accredited Institution - Essential
Completed HIMAA, ICD-10-AM/ACHI/ACS - Introductory Course - Essential.

EXPERIENCE :

1. Minimum of 4 (four) years position-related experience or long practice in inpatient (Internal Medicine) and coding - Essential.
2. Knowledge of Medical coding, Clinical Documentation for RCM - Essential.

BASIC FUNCTION :

Within the mission, vision and values of Saudi Arabian Ministry, provide highly responsible and complex support to the immediate superior and act as an advisor to the healthcare practitioners by providing consultation and guidance on Clinical Documentation Improvement (CDI) best practices consistent with the clinical coding standards, policies, government regulations and accrediting bodies.

MAIN DUTIES AND RESPONSIBILITIES :

1. Responsible for providing complex support to the Director, Health Information Management. Conduct assessment on the coded charts by collaborating with the physicians or healthcare team on clinical documentation/patients' medical records.
2. Discuss gaps analysis and data inconsistencies, conduct research and identify. areas for improvement in the procedures of documentations and codes assignment to ensure data accuracy and completion in the patients' medical records/health information system.
3. Design, develop and implement CDI policies, strategies and plans including instructional materials (if necessary), in collaboration with the hospital administration/medical departments' officials.
4. Work with the CDI staff to conduct work procedural improvement including the proper coordination with the healthcare team for data gathering on patients' health information.
5. Perform interpretation whenever changes are applied in the coding rules and provide guidance to healthcare practitioners and other relevant staff on the implementation of such changes.
6. Provide consultation and advise to the healthcare practitioners on the practicality of using proper clinical coding including the best practices in clinical documentation tation procedures for each medical specialty using real-time clinical cases.
7. Translate clinical cases into quality data metrics, identify lapses and provide solutions to maintain the integrity of clinical documentations/patients' medical records.
8. Guide or mentor CDI staff on how to respond to queries related to the assigned area or to any clinical questions that may arise.
9. Perform case reviews to ensure that the CDI meets criteria for medical necessity and quality improvement program.
10. Provide best practice advice on the content and quality of documentation.
11. Perform other job-related duties.

FUNCTIONAL PROFILE :

1. Responsibility level - Non Supervisory.
2. Systems and Equipment - Area specific applications, Health Information System, Microsoft Office Suite.
3. Expected to use critical thinking skills to reach objective conclusions.

MENTAL DEMANDS : High paced environment with intense deadlines, Great deal of details and accuracy.

This Saudi Arabian Government Ministry Hospitals offers excellent Salary & Benefits along with WORLD CLASS Work Environment.