Clinical Documentation Improvement Specialist

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

📋 Description

• Conduct concurrent reviews of inpatient medical records to verify that documentation is clear, consistent, concise, legible, and accurately reflects the patient’s severity of illness and the intensity of services provided.

• Create and implement queries to clarify physician documentation when there are significant reportable conditions or procedures that may be conflicting, ambiguous, or incomplete.

• Evaluate clinical information to pinpoint gaps in the clinical documentation.

• Engage with the physician advisor to elucidate clinical presentations.

• Work in collaboration with HIM Leadership, coders, Coding Quality Educators/Reviewers, and colleagues to enhance the accuracy of final DRG assignments.

• Offer educational assistance to physicians, nurses, and ancillary staff to enhance clinical documentation practices.

• Facilitate modifications in documentation through collaboration with physicians, nursing staff, caregivers, and Health Information coding personnel to support appropriate reimbursement and accurate clinical severity capture.

• Review cases that have been denied for medical necessity by auditing agencies and assist the physician advisor in appeal processes.

⛳️ Requirements

• A minimum of 3-5 years of relevant experience is required.

• High School Diploma or GED is mandatory.

• A Bachelor's Degree is essential.

• A Bachelor's of Science in Nursing is preferred.

• Certification as a Clinical Documentation Specialist is preferred.

• Certification as a Documentation Improvement Practitioner is preferred.

• Registration as a Nurse in any state is preferred.

• Must be a professional team player with strong communication skills to interact effectively with individuals at all levels.

🏝️ Benefits

• Comprehensive health insurance options.

• Retirement savings plans with employer contributions.

• Opportunities for professional development and continuing education.

• Flexible work schedule options.