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 ensure documentation is clear, consistent, concise, legible, and accurately reflects patients’ severity of illness and intensity of services.

• Create and employ queries to clarify physician documentation when medical records present conflicting, ambiguous, or incomplete information regarding significant reportable conditions or procedures.

• Analyze clinical information to pinpoint deficiencies in clinical documentation.

• Collaborate with the physician advisor to clarify clinical presentations.

• Work alongside HIM Leadership, coders, Coding Quality Educators/Reviewers, and colleagues to enhance final DRG accuracy.

• Offer educational support to physicians, nurses, and ancillary staff to optimize clinical documentation processes.

• Facilitate documentation adjustments by engaging with physicians, nursing staff, caregivers, and Health Information coding personnel to ensure appropriate reimbursement and clinical severity capture.

• Review cases that have been denied for medical necessity by auditing agencies and assist the physician advisor with appeals by gathering relevant information.

⛳️ Requirements

• 3-5 years of relevant experience is required.

• High School diploma or GED is necessary.

• A Bachelor's Degree is required.

• Certification as a Clinical Documentation Specialist is preferred.

• Certification as a Documentation Improvement Practitioner is preferred.

• Registered Nurse license in any state is preferred.

• Must be a professional team player, capable of effective communication with individuals at all levels.

🏝️ Benefits

• Competitive salary and comprehensive benefits package.

• Opportunities for professional development and certification.

• Supportive work environment fostering collaboration and teamwork.