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Clinical Documentation Improvement Job Description
SUMMATIVE REPORT
© 2014
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CDI JOB DESCRIPTION SUMMATIVE REPORT
ahima.org © 2014
IntroductionClinical Documentation Improvement (CDI) has been an ongoing process for monitoring accuracy and efficiency of patient care for decades. 1 The imple-mentation of governmental requirements and expansion of information technology in health care has brought the profession to the forefront in quality management practices. According to Butler (2014 ), “Federal initiatives such as the ‘meaningful use’ EHR Incentive Programs and its numerous quality measures, Medicare and private insurance audits, value-based purchasing, accountable care organizations (ACOs), advancements in health IT, enhanced patient engagement initiatives, and the transi-tion to ICD-10 demand a high volume of clean, granular, accurate, and coded data.” 1 These initiatives have changed the landscape of the healthcare industry and advanced the role of the clinical documentation improvement specialist (CDIS). Building upon the AHIMA Code of Ethics, 2 the AHIMA Ethical Standards for CDI Professionals and the Association of Clinical Documentation Improvement Specialists (ACDIS) Code of Ethics 3 identify principles “intended to assist in decision making processes and actions, outline expectations for making ethical decisions in the workplace, and demonstrate the professionals’ commitment to integrity.” 4 These standards further enable professionals to define the roles and responsibil-ities of the CDIS. According to Brian Murphy, Director of ACDIS, “CDI specialists serve as the bridge between health information management and clinical staff,” 5 providing a vital link for accuracy of documentation and quality patient care (CDI Week, 2013). Recognition of the emerging roles and diversity of the profession is import-ant to the future growth of the field. The purpose of this study is to examine criteria for the CDIS position as listed within CDIS job descriptions. An assessment of CDIS job descriptions provides a descriptive picture of the pro-fession as well as the knowledge and skill sets employers anticipate will be part of the professional’s expertise.
MethodologyIdentification of variables associated with CDI job descriptions was conducted with AHIMA Foundation staff prior to data collection. Members of the AHIMA Foundation team reviewed self-selected job descriptions for Clinical Documentation Improvement Specialists and identified specific variables of interest. Following discussion, thirty-one (31) variables were identified. A data dictionary was developed by the AHIMA Foundation RHIA creden-tialed consultant (see Data Dictionary in Appendix A). Numeric codes were assigned for variables to be entered into an Excel spreadsheet. Based upon reported workforce figures, 337 job descriptions were randomly selected from Internet job search engines (e.g. HCPro, CareerBuilder, SimplyHired, Glassdoor, etc.). Collection of data was randomized by identification and subsequent collection of every other CDI job description. Job descriptions for remote positions were not collected as directed by the AHIMA Foundation leadership. A Confidence Level of 95% and Confidence Interval of 5% was established. An Interrater Reliability of 86% was achieved by two reviewers through an evaluation of 5% of the 337 job descriptions (N=16).
ResultsA total of 337 job descriptions were randomly selected and reviewed resulting in over 10,000 variables (337X 31=10,447). A detailed listing of results shown through Excel data charts can be found in Appendix B. Results are presented by variable.
Project Title: Clinical Documentation Improvement (CDI)
Job Description Summative Report
Submitted By: Susan Hart-Hester, Ph.D., RHIA
Acknowledgement: The report was supported by a philanthropic
contribution from Career Step LLC
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CDI JOB DESCRIPTION SUMMATIVE REPORT
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Title: A number of titles were associated with CDI: 1) Associate, 2) Specialist, 3) Manager, 4) Other, and 5) Director/Supervisor. Data show that 80% (269) of the descriptions specified job titles as CDI Specialist. Eight percent (8%, 28) were CDI Managers with 7% (24) CDI Director/Supervisors. Four percent (4%, 13) identified the CDI along with another job category such as Case Management or Coder. Less than 1% (3) named a CDI Associate in the job description title. Figure 1 depicts CDI job titles as listed in the descriptions reviewed.
Figure 1. CDI Job Titles
80%
1%4%
7%
8%
CDI Job Descriptions By Title
CDI Associate CDI Specialist CDI Manager
Other CDI Director/Supervisor
Department: This variable specifies the department overseeing the CDI work. This category resulted in six identified areas: 1) HIM, 2) Nursing, 3) Other, 4) Not Specified, 5) Revenue/Finance, and 6) Quality Management. Percentages were calculated on subtotals per area following the subtraction of the number of data points designated as “not specified” or missing variables. This resulted in a denominator of 290 (337–47). Data indicate the majority (79%) of CDI work is conducted in the HIM department (228) with Revenue/Finance and Quality Management at 5% (15, 14 respectively). The Nursing department was indicated in 4% (13) of the descriptions reviewed. An additional 20 descriptions (7%) showed other department categories such as Care Coordination. Figure 2 depicts the departments overseeing the CDI work by number.
Figure 2. Departments
228
13 20 15 1447
HIM
Nu
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Oth
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Rev
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inan
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Qu
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Direct Report: This variable assessed whether the CDI had direct report to a designated position or title within the department. Data show 46 job descriptions (14%) specifying direct reporting for the CDI position. Eighty-six percent (86%, 291) of the job descriptions did not specify whether the position had direct reporting responsibilities or a designated position or title for direct report within the department. Figure 3 shows these percentages in a pie chart.
Figure 3. Direct Report
86%
14%
Yes No
Do CDIs Direct Report?
Years of Experience Required and Years of Experience Preferred: Job descriptions were reviewed for the number of years experience required as well as the number of years experience preferred. The number of years required averaged 4.04 years while the average number of years preferred was 3.8 years. Data for both variables ranged from 1 to 10 years. Figure 4 provides a graphic comparison of the average number of years required alongside the average number of years preferred.
Figure 4. Average Years Experience Required and Preferred
Education Required: This variable was categorized into five areas: 1) Associate, 2) Baccalaureate, 3) Graduate, 4) Not Specified, and 5) High School. Percentages were calculated on subtotals per area following the subtraction of the number of data points designated as “not specified” or missing variables. This resulted in a denominator of 304 (337–33). Fifty-three percent (53%, 160) of the job descriptions indicated that a baccalaureate degree was required for the position while 44% (134) required at least an Associate degree. Only 3% (9) required a minimum of a high school diploma while less than 1% (1) required a graduate degree.
Education Preferred: This variable was categorized into four areas: 1) Associate, 2) Baccalaureate, 3) Graduate, and 4) Not Specified. Percentages were calculated on subtotals per area following the subtraction of the number of data points designated as “not specified” or missing variables. This resulted in a denominator of 136 (337–201). Sixty-nine percent (69%, 94) of the job descriptions indicated that a baccalaureate degree was preferred for the position while 23% (32) preferred a graduate degree. Ten descriptions (7%) indicated a preference for an Associate degree.
4.04
3.8
Experience Required Experience Preferred
CDI JOB DESCRIPTION SUMMATIVE REPORT
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Education Required and Preferred: Figure 5 depicts a comparison of the job descriptions by education required and education preferred.
Figure 5. Comparison of Education Required and Preferred
Field Required: This variable was categorized into 7 areas: 1) Nursing, 2) HIM, 3) Either Nursing or HIM, 4) Not Specified, 5) Medical Field 6) Both Nursing andHIM, and 7) Other. Percentages were calculated on subtotals per area following the subtraction of the number of data points designated as “not specified” or missing variables. This resulted in a denominator of 321 (337–16). Fifty-four percent (174) of the job descriptions indicated nursing as a required field while 25% (81) descriptions indicated either nursing or HIM was a required field. Both HIM and Medical fields (e.g. MD, PA, PT, Social Work) were designated in 7% (22) of the job descriptions. Three percent (11) of the job descriptions designated both nursing and HIM as required fields. Less than 1% (2) designated a field other than nursing, HIM or a medical field.
Field Preferred: This variable was categorized into 7 areas: 1) Nursing, 2) HIM, 3) Either Nursing or HIM, 4) Not Specified, 5) Medical Field 6) Both Nursing andHIM, and 7) Other. Percentages were calculated on subtotals per area following the subtraction of the number of data points designated as “not specified” or missing variables. This resulted in a denominator of 96 (337–241). Twenty-eight percent (27) of the job descriptions indicated a preference for the Nursing field while 26% (25) showed HIM as the preferred field. An additional 22% (21) indicated either nursing or HIM as a preference and 18% (17) showed a preference for both nursing and HIM. Only 4% (4) indicated a medical field and 2% (2) showed a field other than nursing, HIM, or a medical field.
Not Specified Preferred
Not Specified Required
Graduate Preferred
Graduate Required
Baccalaureate Preferred
Baccalaureate Required
Associate Preferred
Associate Required
High School Diploma Preferred
High School Diploma Required
201
160
134
33
32
94
10
1
0
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Field Required and Preferred: Figure 6 depicts a comparison of the job descriptions by field required and field preferred.
Figure 6. Comparison of Field Required and Preferred
Certification/License Required: This variable was categorized into 7 areas: 1) Nursing, 2) HIM, 3) Either Nursing or HIM, 4) Not Specified, 5) CDIS only, 6) Both Nursing and HIM, and 7) Other. Percentages were calculated on subtotals per area following the subtraction of the number of data points designated as “not specified” or missing variables. This resulted in a denominator of 315 (337–22). Nursing was the largest category with 56% (178) while either nursing or HIM certifications were required in 78 (25%) of the job descriptions. CDIS only category (N=2) was merged with HIM (N=36) for a total of 11%. Both nursing and HIM requirement and other were designated 10 times each (3%).
Certification/License Preferred: This variable was categorized into 7 areas: 1) Nursing, 2) HIM, 3) Either Nursing or HIM, 4) Not Specified, 5) CDIS only, 6) Both Nursing and HIM, and 7) Other. Percentages were calculated on subtotals per area following the subtraction of the number of data points designated as “not specified” or missing variables. This resulted in a denominator of 114 (337–223). CDIS only category (N=1) was merged with HIM (N=46) for a total of 40%. A preference for Nursing was designated in 26% (30) of the descriptions. Both Nursing and HIM was designated in 17% (19) while either Nursing or HIM was shown in 14% (16). Two (2%) job descriptions designated a preference for a category other than nursing or HIM.
Oth
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Oth
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HIM
Pre
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HIM
Req
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Eit
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HIM
or
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Eit
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HIM
or
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Med
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Fie
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Med
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Pre
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IM &
N
urs
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Bo
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IM &
N
urs
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Pre
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ed
27 25 22 22 17 1621
81
4 2 211
174
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Certification/License Required and Preferred: Figure 7 depicts a comparison of the job descriptions by certification/license required and preferred.
Figure 7. Comparison of Certification/License Required and Preferred
Location: This category was broken into 1) outpatient, 2) acute care, 3) Not specified, 4) specialty care, and 5) other. Percentages were calculated on subtotals per area following the subtraction of the number of data points designated as “not specified” or missing variables. This resulted in a denominator of 334 (337–3). An acute care setting accounted for 99% (331) of the locations specified in the job descriptions. Less than 1% (1, 2) of the job descriptions were designated for specialty care and other, respectively. Figure 8 presents these data.
Figure 8. Job Location
178
30 38 47
78
16 10 19 10 222
223
Nursin
g Req
uire
d
Nursin
g Pre
ferre
d
HIM P
refe
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HIM R
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Either
HIM
or N
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uire
d
Either
Nurs
ing o
r HIM
Pre
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Both N
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IM R
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Both N
ursin
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IM P
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Oth
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Not Spec
ified
Req
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Not Spec
ified
Pre
ferre
d
Not Specified 3
2
1
0
Speciality Care
Acute Care
Outpatient
0 50 100 150 200 250 300 350
Other
331
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Term: This category was designated as: 1) Part-Time, 2) Full-Time, or 3) Not specified. Percentages were calculated on subtotals per area following the subtraction of the number of data points designated as “not specified” or missing variables. This resulted in a denominator of 322 (337–15). Ninety-eight percent (315) of the job descriptions were for full time positions. Only 7 job descriptions (2%) specified part-time positions. Figure 9 illustrates these data.
Figure 9. Term
Full Time98%
Part-Time2%
Term
Essential Job Duties: Fourteen variables were identified as essential job duties. Data were scored as a zero (0) for No and a one (1) for Yes. Summary data from these 14 variables are shown below.
Concurrent Review: This variable was marked as present if the job description(s) specifically mentioned “conducts concurrent review(s)”. Forty-four percent (148) of the job descriptions did not mention conducting concurrent review(s) as part of the job while 56% (189) mentioned conducting concurrent review in the narrative. Figure 10 depicts these data.
Figure 10. Conducts Concurrent Reviews
56%
44%
Yes No
Conducts Concurrent Reviews
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Queries/Interacts/Educates Medical Staff: This variable was marked present if the job description mentioned that the position interacted with and/or educated medical staff/others. Ninety-four percent (317) of the job descriptions specified this function within the narrative; 6% (20) did not mention this job function. Figure 11 presents these data.
Figure 11. Queries/Educates Medical Staff
94%
6%
Yes No
Queries/Educates Medical Staff
Conducts Chart Reviews: Sixty-five percent (219) of the descriptions mentioned conducting chart reviews while 35% (118) did not mention this job function. Figure 12 depicts these data.
Figure 12. Conducts Chart Reviews
65%
35%
Yes No
Conducts Chart Reviews
Completes DRG Worksheets and Documentation: This job function was marked present if the narrative discussed knowledge of DRGs, documentation of DRGs, or other reference to DRGs. Fifty-five percent (184) of the job description narratives mentioned this essential function while 45% (153) did not. Figure 13 illustrates these data.
Figure 13. Completes DRG Worksheets/Documentation
55%
45%
Yes No
Completes DRG Worksheets/Documentation
Knowledge of Care Delivery Systems: This job function was marked present if the description specifically mentioned knowledge of the care delivery system(s). Eighty-three percent (280) job descriptions did not mentioned this job function while 17% (57) specifically mentioned knowledge of care delivery systems. Figure 14 represents these data.
Figure 14. Knowledge of Care Delivery Systems
17%
83%
Yes No
Knowledge of Care Delivery Systems
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Knowledge of Disease Processes: This job function was marked present if the description mentioned knowledge of severity of diseases, Pathophysiology, or co-morbidities. Sixty-one percent (206) of the job descriptions mentioned this function while 39% (131) did not. Figure 15 shows these data graphically.
Figure 15. Knowledge of Disease Processes
61%
39%
Yes No
Knowledge of Disease Processes
Strong Clinical Knowledge: This variable was marked present only if the job description mentioned clinical knowledge in the narrative. Eighty-six percent (289) of the job descriptions did not mention this variable while 14% (48) did mention the need for strong clinical knowledge. Figure 16 shows these data.
Figure 16. Strong Clinical Knowledge
14%
86%
Yes No
Strong Clinical Knowledge
Knowledge of Medicare Requirements: This job requirement was marked present only if the description specifically mentioned knowledge of Medicare or CMS requirements/regulations. Sixty-nine percent (232) of the job descriptions did not mention this knowledge set while 31% (105) descriptions did mention this variable. Figure 17 illustrates these data.
Figure 17. Knowledge of Medicare Requirements
31%
69%
Yes No
Knowledge of Medicare Requirements
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Development of Departmental Budgets: If the job description mentioned the development of departmental budgets or cooperation in the development of budgets then this variable was marked present. Ninety-seven percent (327) of the job descriptions did not mention this function while 3% (10) did mention development of budgets as a job function. Figure 18 illustrates these data.
Figure 18. Development of Departmental Budgets
3%
97%
Yes No
Development of Departmental Budgets
Use of Software Tools: If the job description mentioned the ability to use software tools (e.g. Microsoft Office, analytical tools), then the item was marked present. Fifty-eight percent (194) of the job descriptions mentioned this function while 42% (143) did not. Figure 19 shows these data graphically.
Figure 19. Use of Software Tools
42%
58%
Yes No
Use of Software Tools
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Critical Thinking Skills: If the description mentioned critical thinking skills then the item was marked present. Seventy-two percent (243) of the job descriptions did not mention critical thinking skills as a required skill while 28% (94) descriptions did mention critical thinking. Figure 20 illustrates these data.
Figure 20. Critical Thinking Skills
72%
28%
Yes No
Critical Thinking Skills
Compliance: If job descriptions mentioned compliance, audits, adherence to policies and/or requirements, then the item was marked present. Sixty-seven percent (227) of the descriptions mentioned this function while 33% (110) did not. Figure 21 depicts these data.
Figure 21. Compliance
33%
67%
Yes No
Compliance
Quality Management: Overseeing and/or involvement in quality management efforts (e.g. improving accuracy of documentation) was seen as an essential job function in ninety-seven percent (326) of the job descriptions. Only 3% (11) descriptions did not mention quality management efforts. Figure 22 illustrates these data.
Figure 22. Quality Management
3%
97%
Yes No
Quality Management
Understands Classification Systems: Eighty-two percent (276) of the job descriptions mentioned this skill/knowledge. If the description mentioned knowledge of coding systems (e.g. ICD-9, ICD-10) then the item was marked present. Eighteen percent (61) of the descriptions did not mention knowledge of classification systems as a required skill. Figure 23 illustrates these data.
Figure 23. Understands Classification Systems
18%
82%
Yes No
Understands Classification System
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DiscussionAn overwhelming majority (79%) of the job descrip-tions indicate that the HIM department provides oversight for the functions of the CDIS. According to the data, other fields such as Nursing (4%), Finance (5%), and Quality Management (5%) provide a limited amount of oversight for these specialists. Although job descriptions indicate departmental oversight, very few descriptions (14%) specify a reporting pathway for monitoring/communicating with the CDIS. When a pathway is mentioned, CDIS typically report to the departmental director and/or supervisor.
Data confirm ACDIS’ assertion that the profession “includes a variety of licensed healthcare providers across multiple disciplines.” 6 Job description data reveal the diversity of the CDIS profession including individuals from Nursing, Health Information Management (HIM), and other medical fields (e.g. physicians, physical therapy, and social work). The majority of job descriptions (56%) required a nursing credential; with an HIM credential required only 11% of the time. However, data indicate that 25% of the job descriptions specify a Nursing or HIM credential, further solidifying the two disciplines within the clinical documentation improvement field. Recognizing the departmental/oversight role of the HIM department to these professionals, particularly the nursing professional, needs to be further examined.
While data reveal a requirement for specific credentials associated with the nursing and HIM fields, job description data also disclose a preference for individuals with a higher education (69%) with a baccalaureate degree and/or graduate degree (23%). Interestingly, required educational levels indicate an associate degree (44%) and/or baccalaureate degree (53%), thus adding weight for continuance of two year degree programs. Furthermore, data indicate the required average number of year’s experience is 4 years while the preferred average was 3.8 years.
Clearly, the job functions of the CDIS are “complex and require expert knowledge of clinical care and applicable coding guidelines, as well as an ability to communicate effectively with the clinical care team.” 7 Data confirm this complexity, with involvement in quality management efforts (97%), interaction (querying) medical staff (94%), knowledge of classification systems (82%), knowledge of compliance issues/regulations (67%), chart reviews (65%), and knowledge of disease processes (61%) showing high designations within the job descriptions. According to
Bryant and colleagues, “the CDI professional works to facilitate the overall quality and completeness of clinical documentation to accurately represent the severity, acuity, and risk of mortality profile of the patient being treated;”8 therefore, knowledge of disease processes represents a much needed skill.
Furthermore, Bryant et al state that “the most vital role of a CDI program is facilitating an accurate representation of healthcare services through complete and accurate reporting of diagnoses and procedures.” 8 While the data reveal a majority of descriptions list knowledge of disease processes (61%), knowledge of care delivery systems (17%) and strong clinical knowledge (14%) were not mentioned as frequently. In addition, knowledge of DRG worksheets/documentation (55%) and Medicare requirements (31%), typically designated within CDIS functions, were not listed as often in the job descriptions.
ConclusionData confirm the growth of the CDIS role within the health care industry. An examination of 337 job descriptions reveals the majority of positions held by credentialed individuals, predominately individuals with nursing degrees. While HIM proved to be the lead department for oversight of CDIS professionals, the HIM field was not as represented within the criteria required for the position. A number of descriptions listed a requirement for an associate degree which provides opportunities for individuals from two year educational training programs. However, the average number of year’s experience was four; requiring individuals to gain experience from other positions prior to serving as a CDIS. Results from this study have implications for future research into the role of HIM in the CDIS’s job functions and responsibilities. Moreover, additional examination into the role of two year degree programs and health information credentials within the CDI profession is needed. As documentation improvement continues to expand to address evolving governmental initiatives, the diversity of the CDI profession will continue to grow. Recognizing and embracing this expansion within the field of health information management is vital to the growth and continuance of the field.
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References1. Butler, Mary. “Reinventing CDI: Organizations
Re-launching and Reworking Data Integrity Efforts, and Coding Roles, With Clinical Documentation Improvement Programs.” Journal of AHIMA 85, no.7 (July 2014): 24-27. (p.1)
2. AHIMA Code of Ethics. http://www.ahima.org/about/ethics.asp
3. ACDIS Code of Ethics: Available at http://www.hcpro.com/acdis/code_of_ethics.cfm
4. The AHIMA Ethical Standards for Clinical Documentation Improvement Professionals
5. Murphy, B. (2013). ACDIS CDI Week, Letter to the White House. www.hcpro.com/acdis
6. ACDIS. (2013). Clinical Documentation Improvement Week Fact Sheet. (p.1)
7. ACDIS position paper: Defining the CDI specialist’s roles and responsibilities. http://www.hcpro.com/acdis/details_print.cfm?content_id=303631&topic=WS_ACD_JNL
8. AHIMA. “Guidance for Clinical Documentation Improvement Programs.” Journal of AHIMA 81, no.5 (May 2010): expanded web version. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047343.hcsp?dDocName=bok1_047343
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APPENDIX A.DATA DICTIONARY: CDI JOB DESCRIPTION PROJECT
Data presentation: EXCEL SPREADSHEET Total N: 337 job descriptions
COLUMN A: TITLE
1. CDI Associate
2. CDI Specialist
3. CDI Manager
4. Other (insert title in comment box)
5. CDI Director/Supervisor
COLUMN B: STATE (By abbreviation)
COLUMN C: DEPARTMENT (Work overseen by this department within the facility)
1. HIM (also includes medical records; case management; documenta-tion compliance; CDI; UR/UM; Charge documentation; clinical docu-mentation improvement;)
2. Nursing
3. Other (shown in comment box)
4. NA- Not Specified
5. Revenue/Finance
6. Quality Management (outcomes management; Quality services; Qual-ity Division)
COLUMN D: DO THEY HAVE DIRECT REPORT?
1. Yes (insert comment to show position)
2. No
3. NA- not specified
COLUMN E: YEARS OF EXPERIENCE REQUIRED
Listed by number or range of years
= NA- not given
COLUMN F: YEARS OF EXPERIENCE PREFERRED
Listed by number or range given
0 = NA- not given
COLUMN G: EDUCATION REQUIRED
1. Associate
2. Baccalaureate
3. Graduate
4. NA-Not specified
5. High school diploma
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COLUMN H: FIELD REQUIRED
1. Nursing
2. HIM
3. Either 1 or 2
4. NA-Not specified
5. Medical field (includes MD or PA, or PT, or Social work)
6. Both Nursing & HIM
7. Other
COLUMN I: CERTIFICATION/LICENSES REQUIRED
1. Nursing
2. HIM
3. Either 1 or 2
4. NA-Not specified
5. CDIS
6. Both Nursing & HIM
7. Other
COLUMN J: EDUCATION PREFERRED
1. Associate
2. Baccalaureate
3. Graduate
4. NA-Not specified
COLUMN K: FIELD PREFERRED
1. Nursing
2. HIM
3. Either 1 or 2
4. NA-Not specified
5. Medical field
6. Both Nursing & HIM
7. Other
COLUMN L: CERTIFICATION/LICENSES PREFERRED
1. Nursing
2. HIM
3. Either Nursing/HIM
4. NA-Not specified
5. CDIS only
6. Both Nursing & HIM
7. Other
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COLUMN M: SALARY RANGE Listed by whole dollar amount
0= Not specified Yes = 1 ( select comment- give dollar amount)
COLUMN N: LOCATION
1. Outpatient
2. Acute Care
3. NA-not specified
4. Specialty Care
5. Other
COLUMN O: TERM
1. Part-time 2. Full-Time 3. NA- not specified
COLUMN P: Job Description includes description of essential duties
NO (0) YES (1)
ESSENTIAL JOB DUTIES NO (0) YES (1)
Q. Concurrent Review (designated concurrent review in description)
R. Queries Medical Staff/Interacts/Educates
S. Chart Review
T. Complete DRG Worksheets & Documentation (designated DRG)
U. Knowledge of Care Delivery Systems (designated knowledge of care delivery systems)
V. Knowledge of disease processes (e.g. severity of disease, Pathophysiology, co-morbidities)
W. Strong clinical knowledge (designated clinical knowledge)
X. Knowledge of Medicare requirements
Y. Development of departmental budgets
Z. Able to use appropriate software tools (e.g. Microsoft Office, analytical tools)
AA. Critical thinking skills (also works independently)
AB. Compliance (audits; adherence to policies/requirements)
AC. Oversees/Involved in Quality Management efforts
AD. Understands Classification Systems (Mentioned ICD-9, ICD-10)
AE. Other
COLUMN AF: SOURCE by Name/city/state
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APPENDIX B.CDI DATA CHARTS FROM EXCEL DATA SPREADSHEET
Column A. Job Titles
80%
1%4%
7%
8%
CDI Job Descriptions By Title
CDI Associate CDI Specialist CDI Manager
Other CDI Director/Supervisor
Column C. CDI Works in this Department (By Number of Responses)
228
13 20 15 1447
HIM
Nursin
g
Oth
er
Reven
ue/Fin
ance
Qual
ity M
anag
emen
t
Miss
ing
Column C. CDI Works in this Department (Percentages)Denominator = 290 (337-47 missing values)
79%
5%
4%
5%
7%
Department
Him Nursing Other Revenue/Finance Quality Management
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Column D. Do They Have Direct Report?
14%
86%
Yes No
Strong Clinical Knowledge
Comparison of Column E and F
Comparison of Column G with Column J. Education Required/Preferred
Not Specified Preferred
Not Specified Required
Graduate Preferred
Graduate Required
Baccalaureate Preferred
Baccalaureate Required
Associate Preferred
Associate Required
High School Diploma Preferred
High School Diploma Required
201
160
134
33
32
94
10
1
0
9
Comparison of Column H with Column K. Field Required/Preferred
Oth
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Oth
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No
t S
pec
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Req
uir
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Nu
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Nu
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HIM
Pre
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HIM
Req
uir
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Eit
her
HIM
or
Nu
rsin
g R
equ
ired
Eit
her
HIM
or
Nu
rsin
g P
refe
rred
Med
ical
Fie
ld
Req
uir
ed
Med
ical
Fie
ld
Pre
ferr
ed
Bo
th H
IM &
N
urs
ing
Req
uir
ed
Bo
th H
IM &
N
urs
ing
Pre
ferr
ed
27 25 22 22 17 1621
81
4 2 211
174
4.04
3.8
Experience Required Experience Preferred
ahimafoundation.org
19 |
CDI JOB DESCRIPTION SUMMATIVE REPORT
ahima.org © 2014
Comparison of Columns I and L. Certifications/Licenses by Required/Preferred
178
30 38 47
78
16 10 19 10 222
223
Nursin
g Req
uire
d
Nursin
g Pre
ferre
d
HIM P
refe
rred
HIM R
equi
red
Either
HIM
or N
ursin
g Req
uire
d
Either
Nurs
ing o
r HIM
Pre
ferre
d
Both N
ursin
g & H
IM R
equi
red
Both N
ursin
g & H
IM P
refe
rred
Oth
er R
equi
red
Oth
er P
refe
rred
Not Spec
ified
Req
uire
d
Not Spec
ified
Pre
ferre
d
Column N. Location
Not Specified 3
2
1
0
Speciality Care
Acute Care
Outpatient
0 50 100 150 200 250 300 350
Other
331
Column O. Term
Full Time98%
Part-Time2%
Term
CDI JOB DESCRIPTION SUMMATIVE REPORT
© 2014
Essential DutiesQ. Concurrent Reviews
56%
44%
Yes No
Conducts Concurrent Reviews
R. Queries Medical Staff/Educates
94%
6%
Yes No
Queries/Educates Medical Staff
S. Conducts Chart Reviews
65%
35%
Yes No
Conducts Chart Reviews
20 | ahimafoundation.org
21 |
CDI JOB DESCRIPTION SUMMATIVE REPORT
ahima.org © 2014
W. Strong Clinical Knowledge
86%
14%
Yes No
Strong Clinical Knowledge
X. Knowledge of Medicare Requirements
31%
69%
Yes No
Knowledge of Medicare Requirements
Y. Development of Departmental Budgets
3%
97%
Yes No
Quality Management
T. Completes DRG Worksheets/ Documentation
55%
45%
Yes No
Completes DRG Worksheets/Documentation
U. Knowledge of Care Delivery Systems
17%
83%
Yes No
Knowledge of Care Delivery Systems
V. Knowledge of Disease Processes
61%
39%
Yes No
Knowledge of Disease Processes
22 |
CDI JOB DESCRIPTION SUMMATIVE REPORT
ahimafoundation.org © 2014
AC. Quality Management
3%
97%
Yes No
Quality Management
AD. Understands Classification Systems
18%
82%
Yes No
Understands Classification System
Z. Use of Software Tools
42%
58%
Yes No
Use of Software Tools
AA. Critical Thinking Skills
72%
28%
Yes No
Critical Thinking Skills
AB. Compliance
33%
67%
Yes No
Compliance
© 2014MX10412
About the AHIMA FoundationCreated in 1962, the AHIMA Foundation is a 501(c)(3) charitable arm of the American
Health Information Management Association. Through the generous support of members and industry partners, the AHIMA Foundation advances the HIM profession through innovative
research programs, scholarships and workforce development programs and development of HIM education initiatives. Together we provide Better Health Information for All.
www.ahimafoundation.org
233 N. Michigan Avenue, 21st Floor • Chicago, IL [email protected] • 312-233-1131
Acknowledgement: The report was supported by a philanthropic contribution from Career Step. The AHIMA Foundation gratefully acknowledges their support of this study.