Clinical Documentation Integrity Specialist

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

📋 Description

• Conducts initial case evaluations and a suitable number of follow-up assessments in accordance with program standards. Utilizes clinical judgment and insights from clinical findings to evaluate clinical documentation for potential improvements. Independently formulates complex queries.

• Sustains query rate, response rate, and agreement rate in accordance with established performance metrics.

• Aids in reviewing records across various Inova hospitals as required and under the guidance of designated CDI leaders.

• Engages in all department-wide CDI and coding education concerning ICD-10, MS-DRG, quality outcome measures, and compliance requirements related to queries (AHIMA Practice brief).

• Maintains proficiency in utilizing CDI applications to handle daily work lists and report outcomes of record reviews and queries.

• Inputs all necessary data into CDI applications to assist Coding professionals and Coding Quality Coordinators in determining the outcome of concurrent queries for final MS-DRG, as well as APR-DRG, SOI, ROM, and risk adjustment factors.

• Exhibits expert knowledge of ICD-10 codes and MS-DRG/APR-DRG assignments.

• Collaborates with Coding Quality Coordinators and Coding professionals on inquiries regarding CDI working DRG related to concurrent queries and final coding.

• Supports any post-discharge (retrospective) queries in accordance with CDI policy/procedure and as requested by CDI leadership.

• Demonstrates advanced technical skills with the current software utilized by the department.

• Provides electronic assistance to providers regarding best practice documentation standards and the query process. Delivers 1:1 provider education within the daily workflow and participates in group educational sessions as requested by CDI Leadership.

• Engages in special projects, audits, and other tasks as assigned by CDI Leadership. May assist in mentoring and training new staff.

• Works collaboratively with medical, nursing, and ancillary staff to enhance the quality of chart documentation that ensures appropriate DRG classification, accurately reflecting patient severity of illness and risk of mortality.

• Takes on a leadership role in selected special projects, audits, and other responsibilities as directed by CDI Leadership.

• May travel across the Washington DC metro area to connect with providers as needed.

• May undertake additional responsibilities as assigned.

⛳️ Requirements

• Education: Associate Degree (RN, MD, RHIA/RHIT)

• Experience: Five years of professional experience in inpatient acute care, inpatient clinical, and/or coding roles required. This includes ICU, ER, Peds/NICU, case management/UR, quality, or a similar level of advanced care/coding.

• Two years of CDI experience in an acute inpatient healthcare environment.

• Certification: CDI certification (CCDS or CDIP)

• Licensure: RN, RHIT, or equivalent foreign medical school licensure documentation required based on educational background.

🏝️ Benefits

• Committed to Team Member Health: providing medical, dental, and vision coverage, along with a comprehensive wellness program for team members.

• Retirement: Inova matches the first 5% of eligible contributions, starting from your first day.

• Tuition and Student Loan Assistance: offering up to $5,250 annually in education assistance and up to $10,000 for student loans.

• Mental Health Support: providing all Inova team members, their spouses/partners, and their children with 25 mental health coaching or therapy sessions, per person, per year, at no cost.

• Work/Life Balance: offering paid time off, paid parental leave, flexible work schedules, and remote and hybrid career opportunities.