Clinical Document Integrity Specialist

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

📋 Description

• Conduct both concurrent and retrospective assessments of inpatient medical records to enhance the quality and precision of clinical documentation.

• Recognize opportunities to refine documentation that aids in accurate code assignment, severity of illness, risk of mortality, quality metrics, and reimbursement.

• Work collaboratively with physicians using compliant query practices to secure complete and precise documentation.

• Collaborate with inpatient coding professionals to ensure that documentation supports correct code assignment and accurate DRG allocation.

• Oversee assigned patient populations during their hospitalization and carry out follow-up documentation reviews as necessary.

• Implement current CMS regulations, ICD-10-CM/PCS coding guidelines, MS-DRG methodologies, and guidance from the Coding Clinic.

• Advocate for provider education and best practices in documentation that enhance documentation integrity and patient outcomes.

• Evaluate documentation trends and pinpoint areas for process improvement.

• Engage in multidisciplinary collaboration to further documentation integrity initiatives.

• Uphold productivity, quality, and compliance standards set by HCCS and our client partners.

⛳️ Requirements

• A valid Registered Nurse (RN) license is mandatory.

• Certifications such as CCS, CIC, CDIP, and/or CCDS are preferred but not compulsory.

• A minimum of three (3) years of recent Clinical Documentation Integrity (CDI) experience in a Level I Trauma Academic Medical Center or Teaching Hospital is required.

• Recent experience in concurrent inpatient CDI is essential.

• Experience in reviewing complex inpatient cases within a Level I Trauma academic healthcare setting is necessary.

• Strong knowledge of MS-DRGs, ICD-10-CM/PCS coding guidelines, severity of illness (SOI), risk of mortality (ROM), and compliant physician query practices is vital.

• Proven experience in direct collaboration with physicians and interdisciplinary clinical teams.

• Exceptional critical thinking, analytical, and communication skills are required.

• Familiarity with electronic health records is essential (Epic experience is preferred, if applicable).

• Must possess authorization to work in the United States.

🏝️ Benefits

• Competitive salary.

• Comprehensive benefits package.

• Supportive leadership.

• Opportunities for professional advancement.