Clinical Documentation Improvement Specialist

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

📋 Description

• Enhance the quality and thoroughness of medical records.

• Collaborate in real-time with physicians, nursing staff, case management, medical records coding personnel, and compliance experts.

• Facilitate adjustments in documentation to accurately reflect the level of clinical services, admission reasons, patient severity, mortality risk, and conditions present at admission.

• Review medical record documentation and inform house staff and attending physicians of any deficiencies.

• Compile and record chart findings in the CDI database on a daily basis.

• Provide education to physicians, advanced practice providers, patient resource managers, and case management personnel.

• Examine charts within 24–48 hours of identification and oversee records every 48 hours.

• Conduct follow-up evaluations and maintain documentation of clarification interventions.

• Act as a resource regarding DRG, SOI/ROM, ICD-9, ICD-10, and PCS information.

• Carry out retrospective reviews, reconcile DRG discrepancies with the HIM team, and assist in completing documentation.

• Offer both formal and informal education on techniques for documentation improvement.

• Create and distribute approved literature on documentation improvement.

• Work in collaboration with medical records, finance, and physician groups to enhance documentation systems and data reporting.

• Engage in selected committees and perform associated duties.

⛳️ Requirements

• A BSN, PA (Physician's Assistant), NP (Nurse Practitioner), or a Doctorate degree in a medically related field is mandatory.

• A minimum of three years of progressive healthcare experience in an acute care environment.

• Previous experience and/or training in Case Management/Utilization Review.

• Advanced communication and interpersonal skills with all levels of internal and external stakeholders.

• Exceptional written and verbal communication, critical thinking, creative problem-solving, and conflict management abilities.

• Strong organizational and planning capabilities.

• Proficient in computer skills.

• Proven knowledge of quality improvement theory and practice.

• Currently licensed and/or registered as a professional nurse/physician assistant/MD in the state of North Carolina is preferred.

• CCDS, CCS, or CDIP certification is preferred.

• Previous experience in chart review (case management utilization review) is preferred.

🏝️ Benefits

• Relocation Assistance (based on eligibility).

• One-time commitment bonus of $7500, paid in two equal installments over 12 months at six-month intervals.

• Magnet organization environment.

• Advocacy and support for specialty nursing certification.

• Commitment to equal opportunity and nondiscrimination.

• Support for reasonable accommodations.