Clinical Documentation Integrity Specialist

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

📋 Description

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

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

• Facilitate the clarification and modification of clinical documentation through ongoing interaction with physicians and members of the healthcare team to ensure accurate representation of patient severity and DRG assignment.

• Analyze coding and documentation data to identify trends, variations, and opportunities for documentation enhancement, and communicate findings to management.

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

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

• Assist coding teams by ensuring 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 promote accuracy and consistency in documentation.

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

• Demonstrate knowledge of quality measure initiatives, including Value-Based Purchasing, Pay-for-Performance, readmission reduction programs, and associated regulatory requirements.

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

• Conduct routine audits and reviews of clinical documentation to assess quality, accuracy, and compliance, identifying opportunities for improvement.

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

• Perform additional duties as assigned.

• Utilize, protect, and disclose patients’ protected health information solely 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 duties.

⛳️ Requirements

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

• At least 3 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.

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

• A current state Registered Nurse license is highly preferred.

• Fundamental understanding of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems.

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

• Expertise in Microsoft Office Suite.

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

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

• High level of integrity and dependability, demonstrating 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 for multifactor authentication and security purposes.

• Must be able to follow directions, collaborate with others, and manage stress effectively.

🏝️ Benefits

• Competitive benefits upon hire.

• Ongoing professional development opportunities.

• Full-time permanent remote work.

• Fixed weekends off.

• Day 1 HMO coverage for 2 dependents at no cost.

• Medical cash allowance.

• Rice allowance.

• Clothing allowance.

• Daily free lunch.

• Paid time off.

• Training and staff development.

• Employee engagement activities.

• Opportunities for internal mobility.