Clinical Documentation Improvement Specialist

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

📋 Description

• Accountable for conducting concurrent reviews of patient records to ensure that clinical documentation is complete, accurate, and specific.

• Should possess a thorough understanding of ICD and CPT Coding Guidelines.

• Tasked with clarifying unclear, incomplete, or conflicting documentation by proactively seeking answers and educating providers.

• Engage in ongoing efforts to enhance clinical documentation to accurately reflect the care delivered and the corresponding reimbursement.

• Responsible for elevating the overall quality and completeness of clinical documentation.

• Facilitate enhancements to clinical documentation through extensive concurrent collaboration with physicians, nursing staff, other patient caregivers, and Coding staff to ensure that appropriate reimbursement, clinical severity of illness, and risk of mortality is captured for the level of service provided to all patients.

• Support the timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and practice outcomes.

• Provide ongoing education to all members of the patient care team.

⛳️ Requirements

• Must hold an Associate’s degree in Healthcare, Nursing, or a related field, or possess an equivalent combination of education and experience.

• Must have training in medical terminology, anatomy, and physiology.

• Must be trained and certified in coding, or have an equivalent combination of education and experience.

• Three to five years of CDI experience is preferred.

• Must have a certification; Certified Documentation Expert Inpatient (CDEI), Certified Clinical Documentation Specialist (CCDS), Certified Professional Coder (CPC), or Certified Coding Specialist (CCS) with coding or clinical documentation integrity experience.

• Comprehensive knowledge of medical record content is required.

• Extensive understanding of coding/classification systems (ICD & CPT) and related coding guidelines is necessary.

• Experience in compliant healthcare documentation, HCC coding requirements, and alternate payment models within a multi-facility, revenue cycle context.

• Basic computer skills are needed.

• Should be familiar with coding software (encoders).

• Should have knowledge of LDC/NCD (or know how to research this) and Quality Measures.

🏝️ Benefits

• Health insurance

• 401(k) matching

• Flexible working hours

• Paid time off

• Professional development opportunities