Concurrent Coding/CDI Specialist

Clinical Documentation Improve - 208411 Winchester, Virginia Full-Time


  • Entity:
  • Shift: Day

Who We Are

Valley Health System is a not-for-profit network of hospitals, urgent cares, physician practices, and services. Expanding across Virginia, West Virginia, and Maryland, we are devoted to the health of all who call our 18-county area home.

A vital resource for healthcare, we are the region’s largest employer, a dependable community partner, and are at the leading edge of clinical innovations.

We are looking for passionate, innovative, and caring people who will each bring their unique skills and perspectives to our workplace.

What You Will Do:

The Concurrent Coding/CDI Specialist collaborates extensively with Clinical Documentation Specialists and Clinical Documentation Improvement Manager, physicians, nursing staff, other patient caregivers, and medical records coding staff / HIM to improve quality and completeness of documentation of care provided and coded. Reviews and codes accounts that need Concurrent Coding and DRG assignment. Concurrently reviews patient charts and assigns appropriate codes to diagnoses and procedures, in order to establish a working DRG. Ensures high quality documentation that is thorough, accurate and complete to ensure accurate reimbursement capture. Reviews charts and entire medical records, assigning ICD codes to each data element. Concurrently reviews and manages the most complex coding cases. Works closely with Clinical Documentation Improvement Specialist and clinicians to capture accurate documentation. Enters findings of concurrent coding reviews into CDI Software application. Effectively uses applicable software applications to assign codes, determines a DRG and accurately enters codes into computer. Facilitates concurrent modifications to clinical documentation to ensure accurate DRG assignment, clinical severity and services rendered to all patients. Supports timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. Audits for documentation opportunities and queries clinical staff with CDI to fill in any gaps, clarify confusing, incomplete or conflicting information and obtain any needed additional documentation in real time. Contacts and works with physicians as needed for clarification of details of disease process or clarification of documentation to ensure correct coding. Expedites charts as necessary to obtain additional physician documentation. Assists in obtaining required Present on Admissions documentation. Records and sequences clinical data in correct order using national definitions of the Uniform Hospital Discharge Data Set (UHDDS). Applies transfer rule for correct discharge disposition of records according to established policy. Ensures coding compliance; applies all coding guidelines and principles as defined in the Coding Clinic, and leading authorities. Complies with standardized coding standards and conventions and regulations, corporate compliance standards, and reimbursement policies. Stays current on all Medicare and other Governmental payer rules/updates. Maintains department best practice productivity and quality standards. Actively participates in DRG assurance program. Discusses coding questions with CDI team and Supervisor and reports unusual occurrences to Supervisor, Director of Health Information Management, or Compliance officer. Acts as a technical resource; facilitates problem/issue resolution. Makes suggestions and recommendations for improvements. Assists in performance of all quality initiative medical audits. Collaborates with HIM leadership for an effective department and smoothly running process. Covers for absences/vacations. Works professionally with all customers (MD's, departments, nursing, etc). Assists HIM management on chart audit reviews, as assigned.

What You Will Bring:


Associates required
Successful completion of ICD-10-CM/PCS courses required
Successful completion of CPT Coding course required
Successful completion of Medical Terminology course required
Successful completion of Anatomy and Physiology course required

Five years recent inpatient coding experience required
Five years recent clinical nursing experience in acute care preferred
Clinical documentation improvement experience preferred
Outpatient coding experience preferred

Certification & Licensures
Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT), or Certified Coding Specialist (C.C.S.) required
CDI credential within 2 years of hire, either the Certified Clinical Documentation Specialist (CCDS) through ACDIS or the Certified Documentation Improvement Practitioner Credential (CDIP) through AHIMA required
Graduate of an accredited nursing program and licensed or eligible for licensure in the Commonwealth of Virginia as a Registered Nurse preferred

Working knowledge of care delivery documentation systems and related medical record documents required
Working knowledge of inpatient admission criteria required
Ability to work independently in a time oriented environment required
Computer literacy and familiarity with the operation of basic office equipment required
Understanding of anatomy & physiology and pathophysiology of disease processes required
Excellent written and verbal communication skills required
Critical thinking skills and interpersonal skills to build effective partnering relationships with physicians, care management team, nursing staff and coding staff required
Knowledge of principle diagnosis and secondary diagnoses that accurately reflect severity of illness and expected treatment required
Demonstrated ability to extract data, evaluate data, compare data to establish criteria and communicate data required
Ability to interact with others using discretion, resourcefulness and persuasiveness while maintaining professional attitude required Attention to detail oriented required
Ability to maintain confidentiality required
Strong analytical and problem solving skills required

What You Will Get:

- Competitive salary
- Flexible scheduling
- Onsite Childcare (available at some locations)
- Health Insurance
- Paid Time Off
- Wellness Program
- Tuition Assistance
- Retirement Plan
- Life Insurance

*some benefits are subject to change due to job status

We celebrate, support, and thrive on our differences for the benefit of our employees, our patients, and the communities we serve.
We are neighbors caring for neighbors, and our goal is always to help those we serve get well, feel well, and stay well.


Criminal Background Checks
VA State Police
3rd party Background Check

FLSA Classification


Physical Demands
6 A Customer Service