CDI Consultant

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

📋 Description

• Conduct prompt evaluations of patient medical records to ensure documentation is both accurate and comprehensive.

• Collaborate with healthcare providers and coders to confirm that documentation accurately captures the complexity of the patient’s condition.

• Provide education and engage with healthcare providers.

• Ensure that inpatient clinical documentation accurately reflects the severity of illness (SOI) and Risk of Mortality (ROM).

• Accurately document Present on Admission (POA) clinical conditions within stipulated regulatory timelines.

• Participate in educational sessions, offering feedback to coders, CDI Reviewers, and Hospital Quality Departments.

• Perform regular audits utilizing standardized methodologies to guarantee compliance with POA, HACs, and PSI documentation standards.

• Monitor and analyze data for quarterly data quality reviews for the CDI and Coding team.

• Raise concerns regarding any issues that may affect documentation quality or coding.

• Ensure compliance with CMS rules and regulations regarding coding and DRG assignment.

⛳️ Requirements

• RN licensure is required.

• Experience with Iodine is necessary.

• A minimum of 2 years in clinical documentation is required.

• Strong background in clinical training is essential.

• APR experience is necessary.

• At least 3 years of acute care experience is required.

• Strong analytical abilities to assess the medical record clinically.

• Proficiency in using a PC for medical record review and familiarity with Microsoft products (Excel, Word, Outlook) is required.

• Effective communication skills with e4health management and clients are essential.

• BSN is preferred.

• Experience with Smarter Dx is desirable.

• Familiarity with Epic and 3M is advantageous.

🏝️ Benefits

• 401(k) plan with company match.

• Medical insurance coverage.

• Dental insurance coverage.

• Vision insurance coverage.

• Life insurance coverage.

• Short-term and long-term disability insurance.

• Paid Time Off (PTO) policy.