Clinical Documentation Integrity Specialist

This is a fully remote position, open to applicants in Alabama, +15 more states.

📋 Description

• Perform basic to intermediate initial, concurrent, and retrospective clinical documentation reviews for selected admissions.

• Extract data from concurrent and retrospective charts as well as computerized data systems, adhering to Official Coding Guidelines and Official Query Guidelines.

• Assign and update ICD-10-CM/PCS codes along with baseline and working MS-DRG and APR-DRG assignments.

• Recognize documentation clarification requirements and communicate these needs with providers utilizing appropriate query tools.

• Evaluate clinical validation denials and analyze recommendations for appeals.

• Draft first- and second-level denial appeals in collaboration with the physician advisor.

• Complete second-level, mortality, and quality reviews.

• Engage in staff training and participate in departmental improvement initiatives.

• Use quality audit findings to drive changes in practice.

• Collaborate with coders to ensure accurate DRG assignments.

• Work closely with interdisciplinary team members, including participating in physician rounds and team conferences.

• Participate in professional development activities through webinars, online education, and virtual meetings.

• Meet CDI quality and productivity targets.

• Carry out additional duties as assigned.

⛳️ Requirements

• Candidates must reside in Alabama, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Minnesota, Missouri, Mississippi, Nebraska, North Carolina, Oklahoma, Texas, Utah, or Virginia for remote employment.

• An Associate's Degree in Nursing is required.

• A minimum of 3 years of clinical experience in an ICU/Critical Care acute care setting is required.

• Registered Nurse (RN) state licensure or compact state licensure in the designated work state is required upon hire.

• Certification as a Clinical Documentation Specialist (CCDS) is required within 2 years, or Certification as a Documentation Improvement Practitioner (CDIP) is required within 2 years.

• Proficiency in inputting and retrieving data, answering phones, communicating clearly, and demonstrating precise hand-eye coordination, fine motor skills, and strong writing abilities.

• Clinical competencies are essential.

• Ability to manage interruptions and demonstrate flexibility in hours and workflow.

• Strong communication and critical thinking skills are necessary.

• Familiarity with care delivery documentation systems and associated medical record documents is important.

• Knowledge of age-specific requirements and disease processes is required.

• Capability to read and interpret medical records, analyze encoder instructions, and understand documentation.

• Ability to work independently, maintain attention to detail, and prioritize tasks effectively.

• Ability to spend extended periods looking at a computer screen, typing, and sitting.

• Visual and auditory abilities are essential.

• A Bachelor's Degree in Nursing is preferred.

• At least 1 year of experience in clinical documentation integrity functions is preferred.

🏝️ Benefits

• Concierge services.

• Employee lounge.

• Wellness programs.

• Free covered parking.

• Free on-site and virtual health clinics.

• Compensation and recognition.