Clinical Documentation Integrity Specialist

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

📋 Description

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

• Conduct concurrent chart evaluations to ensure clinical documentation accurately represents the patient’s condition, complexity of care, and services provided to facilitate proper coding and reimbursement.

• Assist in clarifying and modifying clinical documentation through real-time collaboration with physicians and other members of the healthcare team.

• Assess coding and documentation data to identify trends, discrepancies, and opportunities for improvement, and report findings to management.

• Leverage data analytics, DRG reports, and tracking tools to monitor documentation performance and support initiatives for performance enhancement.

• Collaborate with physicians, nurses, coders, and other healthcare professionals to clarify documentation and gather additional information.

• Aid coding teams by ensuring documentation supports code assignment and adheres to coding guidelines and regulatory standards.

• Communicate with coding personnel and healthcare providers to resolve coding-related challenges.

• Conduct training and educational sessions for providers and staff on documentation best practices, coding guidelines, compliance requirements, and quality initiatives.

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

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

• Perform routine audits and reviews of clinical documentation to assess quality, accuracy, and compliance.

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

• Utilize, protect, and disclose patients’ protected health information in accordance with HIPAA standards.

• Adhere to Information Security and HIPAA policies and procedures.

• Limit access to PHI to the minimum necessary for performing assigned responsibilities.

• Execute other duties as assigned.

⛳️ 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 required.

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

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

• Certification minimum requirement includes CCDS and/or CDIP.

• Coding credentials (CCS, CPC, CCS-P) are advantageous.

• A current state Registered Nurse license is highly preferred.

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

• Proficient in CDI tools such as encoder or CDI workflow and reporting tools.

• Proficiency in Microsoft Office Suite is necessary.

• Strong interpersonal skills with the ability to communicate effectively at all organizational levels.

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

• High integrity and reliability, with a strong sense of urgency and results orientation.

• Exceptional written and verbal communication skills are required.

• Must possess a smartphone or electronic device capable of downloading applications.

• Ability to follow instructions, collaborate with others, and manage stress effectively.

🏝️ Benefits

• Opportunity for remote work.

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