Clinical Documentation Integrity Specialist

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

📋 Description

• Evaluate medical records to identify documentation that is incomplete, inconsistent, or inaccurate concerning diagnoses, treatments, procedures, severity of illness, and risk of mortality.

• Conduct concurrent chart reviews to ensure that clinical documentation accurately represents patient conditions, the complexity of care, and services rendered to support appropriate coding and reimbursement.

• Facilitate the clarification and modification of clinical documentation through collaboration with physicians and healthcare team members.

• Analyze coding and documentation data to identify trends, variations, and opportunities for enhancing documentation; share findings with management.

• Employ data analytics, DRG reports, and tracking tools to monitor documentation performance and uncover gaps.

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

• Assist coding teams by ensuring that documentation supports code assignment and adheres to coding guidelines and regulatory requirements.

• Communicate with coding staff and healthcare providers to resolve coding-related issues and advocate for documentation accuracy.

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

• Leverage knowledge of Value-Based Purchasing, Pay-for-Performance, readmission reduction programs, and associated regulatory requirements.

• Ensure that clinical documentation is in alignment 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 documentation integrity, coding accuracy, and operational performance.

• Safeguard and disclose PHI in accordance with HIPAA standards.

• Adhere to Information Security and HIPAA policies and procedures.

• Limit access to PHI to the minimum necessary.

⛳️ Requirements

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

• A high school diploma or equivalent is required.

• At least 3 years of experience in a clinical documentation improvement role is required.

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

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

• Certification in CCDS and/or CDIP is a minimum requirement.

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

• A current state Registered Nurse license is highly preferred.

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

• Proficiency in CDI tools such as encoders or CDI workflow and reporting tools is necessary.

• Competence in Microsoft Office Suite is required.

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

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

• A high level of integrity and dependability, combined with a strong sense of urgency and results orientation, is required.

• Exceptional written and verbal communication skills are mandatory.

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

• Ability to follow directions, collaborate with others, and manage stress effectively is essential.

🏝️ Benefits

• Remote work arrangement.

• Multifactor authentication and security device support requirement (smartphone or electronic device capable of downloading applications).