Clinical Documentation Integrity Specialist

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

📋 Description

• Evaluate medical records to pinpoint incomplete, inconsistent, or erroneous documentation related to diagnoses, treatments, procedures, severity of illness, and mortality risk.

• Conduct concurrent chart reviews to verify that clinical documentation accurately portrays the patient’s condition, complexity of care, and services provided to facilitate appropriate coding and reimbursement.

• Assist in the clarification and alteration of clinical documentation through real-time interactions with physicians and healthcare team members to ensure precise representation of patient severity and DRG assignment.

• Regularly analyze coding and documentation data to uncover trends, variations, and areas for documentation enhancement, and relay findings to management.

• Leverage data analytics, DRG reports, and tracking tools to oversee documentation performance, identify gaps, and bolster performance improvement initiatives.

• Work collaboratively with physicians, nurses, coders, and other healthcare professionals to clarify documentation and gather additional information necessary for accurate and compliant coding.

• Support coding teams by ensuring that documentation justifies code assignment and adheres to coding guidelines and regulatory standards.

• Engage in effective communication with coding staff and healthcare providers to address coding-related concerns and encourage documentation accuracy and consistency.

• Organize training and educational sessions for providers and staff on best practices in documentation, coding guidelines, compliance requirements, and quality initiatives, as requested by CDI leadership.

• Exhibit knowledge of quality measure initiatives, including Value-Based Purchasing, Pay-for-Performance, readmission reduction programs, and relevant regulatory standards.

• Ensure that clinical documentation complies with organizational policies, coding standards, regulatory mandates, and payer guidelines.

• Perform routine audits and reviews of clinical documentation to assess quality, accuracy, and compliance, while identifying areas for enhancement.

• Engage in quality improvement initiatives aimed at enhancing clinical documentation integrity, coding precision, and operational efficiency.

⛳️ Requirements

• A BSN, PA (Physician's Assistant), NP (Nurse Practitioner), or a Doctorate degree in a medically related field is required.

• A high school diploma or equivalent is required.

• A minimum of 3 years of experience in a clinical documentation improvement role is preferred.

• A minimum of 5 years of nursing experience in adult acute care settings such as med/surg, critical care, emergency, or PACU is required.

• An active RN, MD, DO, NP, or PA license is required.

• The minimum certification requirement includes CCDS and/or CDIP.

• A coding credential (CCS, CPC, CCS-P) is considered a plus.

• A current state Registered Nurse license is highly preferred.

• Fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems is necessary.

• Proficiency in CDI tools, such as encoder or CDI workflow and reporting tools, is essential.

• Competence in Microsoft Office Suite is required.

• Strong interpersonal skills with the ability to communicate effectively across all levels of the organization are essential.

• Demonstrated problem-solving and creative skills, along with the ability to exercise sound judgment and make decisions based on accurate and timely analyses, are required.

• A high level of integrity and dependability, coupled with a strong sense of urgency and results-oriented mindset, is necessary.

• Excellent written and verbal communication skills are required.

🏝️ Benefits

• Must have a smartphone or electronic device capable of downloading applications for multifactor authentication and security purposes.