Clinical Documentation Integrity Specialist

Clinical Documentation Integrity Specialist (CDI)

Job Type: PT | Days 

Your experience matters

At Willamette Valley Medical Center, we are driven by a profound commitment to prioritize your well-being so you can provide exceptional care to others. Here, you're not just valued as an employee, but as a person. As a Clinical Documentation Integrity Specialist (CDI) joining our team, you're embracing a vital mission dedicated to making communities healthier. Join us on this meaningful journey where your skills, compassion, and dedication will make a remarkable difference in the lives of those we serve.

 Department/Unit Summary

The CDI Specialist will work with physicians and other providers to improve the overall quality and completeness of clinical documentation in the medical record to ensure that an accurate reflection of the severity of illness and the quality of care is captured. The CDI Specialist works to educate providers on the value of more granular documentation to their quality scores, risk of mortality data, length of stay and continuity of care for the patient. The Specialist, in conjunction with the CDI team and HIM Leadership, will assist the effort to ensure that accurate DRG-based reimbursement for the hospital is achieved and claims denials are reduced, by ensuring documentation integrity.

 Essential Job Functions

• Ensures that provider documentation provides an accurate reflection of the patient's severity of illness and that appropriate diagnoses are rendered with adequate specificity, by concurrently reviewing all relevant inpatient admissions, performing a gap-analysis to determine where short-falls exist in the progress notes, and verbally and/or in written communications to the providers address and identify options for appropriate specificity that may be lacking.
• Assists the CDI team in providing education to operational leaders, staff and physicians on the importance of the Clinical Documentation Integrity Program (CDIP), and works cooperatively with them to ensure that improved documentation is seen as a part of the strategic mission.
• Facilitates modifications to clinical documentation through extensive concurrent interactions with physicians, nursing staff and coding teams to ensure that appropriate reimbursement and severity of illness (SOI) is captured
• Responsible for attaining Key Performance Metrics and Financial goals set annually by the facility in conjunction with the system.
• Assists the assigned coder with concurrently reviewing the medical records of inpatients and subsequently discusses documentation opportunities with the various physician teams
• Acts as consultant to coders when additional information or documentation is needed to assign the correct principal diagnosis, secondary diagnoses and appropriate DRG.

Connect with our recruiting specialist 

Not ready to complete an application, or have questions? Please contact Jarod Grem by emailing [email protected]

 What we offer

Fundamental to providing great care is supporting and rewarding our team. In addition to your base compensation, this position also offers:  

• Comprehensive medical, dental, and vision plans, plus flexible-spending and health- savings accounts  
• Competitive paid time off for full-time employees 
• Income-protection programs, such as life, accident, critical-injury insurance, short- and long-term disability, and identity theft coverage 
• Tuition reimbursement, loan assistance, and 401(k) matching  
• Employee assistance program including mental, physical, and financial wellness 
• Professional development and growth opportunities

Qualifications and requirements

• Minimum 3 years clinical work experience required; Critical care, ICU or ER experience preferred.
• A strong knowledge of pathophysiology and treatment management across multiple practice areas is required. 
• Knowledge of ICD 10, coding or billing is desirable.
• Strong computer skills including MS Office and internet based software programs.

About our Health System

Willamette Valley Medical Center is a 60-bed hospital located in McMinnville, OR, and is part of Lifepoint Health, a diversified healthcare delivery network committed to making communities healthier® with acute care, rehabilitation, and behavioral health facilities from coast to coast. From your first day to your next career milestone-your experience matters.

EEOC Statement

"Willamette Valley Medical Center is an Equal Opportunity Employer. Willamette Valley Medical Center is committed to Equal Employment Opportunity for all applicants and employees and complies with all applicable laws prohibiting discrimination and harassment in employment."

Lifepoint Health is a leader in community-based care and driven by a mission of Making Communities Healthier. Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities. We believe that success is achieved through talented people. We want to create places where employees want to work, with opportunities to pursue meaningful and satisfying careers that truly make a difference in communities across the country.