Clinical Documentation Improvement Specialist

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

📋 Description

• Perform both concurrent and retrospective clinical reviews of inpatient medical records.

• Assess clinical documentation and pinpoint areas for enhancing medical record quality.

• Conduct mortality assessments, PSI evaluations, and other projects focused on CDI leadership.

• Guide physician documentation regarding conditions and procedures that reflect the severity of illness, anticipated mortality risk, and complexity of care.

• Initiate communication with physicians through queries and participation in rounding when records have unclear, incomplete, or conflicting information.

• Provide education to physicians and staff about documentation standards, coding regulations, and reimbursement policies.

• Assign working DRGs and review medical records throughout hospitalization to ensure the highest coding specificity.

• Collaborate with coders, auditors, quality improvement teams, and other relevant stakeholders to address documentation challenges.

• Keep updated on clinical documentation standards, coding regulations, compliance requirements, CMS updates, and Coding Clinic Guidelines.

• Engage in documentation improvement projects and participate in formal or informal educational initiatives.

• Assist in onboarding and training new members of the CDI team.

⛳️ Requirements

• An Associate’s Degree in Nursing is required; a Bachelor’s Degree in Nursing is preferred.

• Three to five years of recent clinical experience in medical-surgical, ICU, telemetry, and/or emergency department environments.

• An active RN license in the US is required.

• Familiarity with electronic medical record (EMR) systems and CDI platforms.

• Proficient in CDI methodologies, coding, and documentation standards associated with quality results, medical record accuracy, and reimbursement.

• Up-to-date knowledge of CMS regulations and guidelines.

• Capability to navigate electronic calendars, MS Teams, MS SharePoint, OneDrive, CDE One, and various CDI software applications.

• Strong interpersonal skills.

• Capacity to take initiative, work autonomously, and stay self-motivated.

• Ability to tackle moderately to highly complex issues.

• Basic computer skills, including proficiency in Word, Excel, PowerPoint, and Outlook/email.

• Skill in providing and receiving constructive and positive feedback.

• Excellent judgment, critical thinking capabilities, and independent decision-making skills.

• Knowledge of hospital coding sets, policies and procedures, federal and state reimbursement guidelines, and Coding Clinic Guidelines.

🏝️ Benefits

• Annual bonus plan with a target of 5.00%.

• Comprehensive benefits package.

• Opportunities for continuous learning, cross-group collaboration, and exploring new career paths.

• Workplace support and reasonable accommodations for applicants with disabilities.