Clinical Documentation Integrity Specialist

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

📋 Description

• Perform thorough initial and follow-up concurrent reviews of medical records.

• Recognize opportunities to clarify incomplete or conflicting documentation and confirm diagnoses.

• Draft compliant written queries for treating physicians in accordance with ACDIS/AHIMA guidelines.

• Determine principal and secondary diagnoses as well as significant procedures to assign working MS-DRG.

• Establish and update working DRGs based on record documentation and anticipated length of stay.

• Utilize approved query templates and reference relevant clinical indicators.

• Leverage knowledge of PSI, HAC, SOI/ROM, and present-on-admission status.

• Adhere to hospital protocols for documentation requirements, query escalation, and DRG reconciliation.

• Monitor physician query responses in the medical record.

• Maintain productivity and quality performance metrics.

• Utilize CDI applications to prioritize worklists, document review outcomes, and track queries.

• Input necessary data to support final MS-DRG, SOI, and ROM assignments.

• Refer to electronic coding resources, Official Coding Guidelines, and Coding Clinic.

• Collaborate with the Coding team on ICD-10 coding, MS-DRG assignments, and queries.

• Engage in DRG reconciliation and participate in departmental committees or task forces.

• Contribute to a positive and collaborative work atmosphere.

• Adhere to HIPAA regulations and code of conduct policies.

⛳️ Requirements

• Bachelor’s degree (Relevant experience may replace formal education or advanced degree).

• At least one of the following: RN, MD or MD Equivalent, RHIA, RHIT, CCS, with a current/active license.

• Minimum of 2 years of acute care inpatient hospital coding or CDI experience.

• Familiarity with encoder and DRG assignment processes.

• Maintain up-to-date knowledge of official coding guidelines and coding clinics.

• CCDS or CDIP certification is preferred.

• Strong clinical insight into disease processes.

• Excellent critical thinking, analytical abilities, and problem-solving skills.

• Comprehensive knowledge of medical terminology, anatomy, physiology, microbiology, and disease processes.

• Outstanding communication skills.

• Capability to engage with physicians in challenging situations.

• Proficient typing and computer skills.

• Experience with EHR systems, CDI software systems, and encoders.

🏝️ Benefits

• Medical, Rx, Dental & Vision Insurance.

• Personal and Family Sick Time & Company Paid Holidays.

• Potential availability of a discretionary variable incentive bonus.

• Parental Leave.

• 401(k) Retirement Plan.

• Basic Life & Supplemental Life Insurance.

• Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts.

• Short-Term & Long-Term Disability Insurance.

• Tuition Reimbursement, Personal Development & Learning Opportunities.

• Skills Development & Certifications.

• Employee Referral Program.

• Corporate Sponsored Events & Community Outreach.

• Emergency Back-Up Childcare Program.

• Flexible benefits package.