This is a fully remote position, open to applicants in United States.

📋 Description

• Review clinical documentation to guarantee accuracy, completeness, and adherence to regulatory guidelines and coding standards.

• Assess the effectiveness of Clinical Documentation Improvement (CDI) programs.

• Identify gaps in documentation.

• Offer feedback and training to enhance documentation quality, coding precision, and reimbursement integrity.

• Conduct high-level secondary case reviews to ensure thorough and accurate provider documentation.

• Execute CDI audits.

• Evaluate documentation alignment with ICD-10-CM/PCS, MS-DRG/APR-DRG, and payer guidelines.

• Detect missed or inappropriate diagnoses, procedures, CCs/MCCs, and opportunities related to the severity of illness (SOI) / risk of mortality (ROM).

• Analyze audit results and compile comprehensive reports detailing trends, risks, and areas for improvement.

• Provide guidance and education to CDI specialists, coders, and clinical staff.

⛳️ Requirements

• RN Required.

• CCDS or CDIP certification is preferred but not mandatory.

• At least 3 years of experience in CDI.

• Minimum of 2 years of bedside nursing experience in an acute care environment (ICU, Med/Surg, ED, etc.).

• A clinical background with an in-depth understanding of official medical coding guidelines, CMS, and private payer regulations concerning the Inpatient Prospective Payment System.

• Experience in conducting CDI audits and secondary reviews.

• Ability to engage with physicians and hospital personnel in a collaborative manner to foster appropriate clinical documentation and quality enhancement.

• Availability for full-time work.

• Capability to work remotely.