Clinical Documentation Integrity Specialist

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

📋 Description

• Assess and analyze medical record documentation for completeness, precision, and adherence to compliance standards.

• Work closely with physicians, nurses, and coding specialists to guarantee proper clinical documentation practices.

• Spot opportunities for enhancing documentation to bolster coding accuracy, reimbursement, and clinical outcomes.

• Examine medical records to confirm that documentation upholds quality care and ensures appropriate reimbursement.

• Develop compliant and clinically robust queries for physicians.

⛳️ Requirements

• At least 2 years of experience in inpatient clinical documentation improvement (CDI).

• A minimum of 2 years of bedside nursing experience in an acute care environment (ICU, Med/Surg, ED, etc.).

• Valid Registered Nurse (RN) certification is mandatory.

• CCDS/CDIP certification is preferred but not essential.

• Familiarity with ICD-10-CM, MS-DRGs, coding guidelines, and compliance regulations.

• Strong communication, critical thinking, and organizational abilities.

• Proficient in using MS Office, email, VPNs, virtual machines, two-factor authentication, and video conferencing platforms (MS Teams, Zoom, etc.).

• Experience with 3M and Epic software is preferred but not a requirement.

🏝️ Benefits

• Comprehensive benefits package.

• Paid Time Off (PTO).

• Competitive salary.

• A collaborative, mission-driven team atmosphere.

• Opportunities for ongoing learning, education, and professional development.

• Leadership that appreciates your expertise and contributions.