Clinical Documentation Integrity Specialist

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

📋 Description

• Guarantees the accuracy and completeness of documentation by conducting timely reviews of medical records and determining code assignments through the application of clinical and/or coding expertise to identify opportunities for enhanced or clarified documentation that accurately represents the patient.

• Ensures prompt follow-up with clinical providers to obtain the necessary clarifications.

• Takes responsibility for expanding knowledge in Clinical Documentation Improvement (CDI) and coding, staying current with the latest research, technology, treatment methods, etc.

• Actively participates in educating physicians and other clinical care providers on clinical documentation through various formats, including involvement in clinical rounding, service line-focused educational sessions, and individualized case-specific feedback.

• Utilizes knowledge of healthcare workflows to collaborate effectively with medical staff and other healthcare team members to enhance the overall accuracy and thoroughness of medical record documentation, with an emphasis on ensuring precise reporting of quality outcomes.

• Achieves established operational and productivity benchmarks, consistently meeting productivity, quality, and AHIMA ethical standards.

⛳️ Requirements

• Associate's Degree in a health-related field (Required) or another Accredited Program: Diploma in Nursing (Required)

• Over 3 years of clinical and/or ICD-10 coding experience, preferably within a large academic medical center (Required)

• At least 1 year of experience utilizing clinical computer systems (Required)

• Must possess thorough and current clinical skills (i.e., up-to-date knowledge of pathology, pharmacology, surgical procedures, etc.). (Required proficiency)

• Exceptional written and verbal communication abilities, including presentation skills. (Required proficiency)

• Capable of functioning independently as well as being a team player in a fast-paced setting. (Required proficiency)

• Detail-oriented with strong relationship-building skills. (Required proficiency)

• Demonstrates extensive knowledge of disease pathophysiology (Required proficiency)

• Registered Nurse (RN), Ohio and/or Multi-State Compact License (Required Upon Hire), or Registered Health Information Administrator (RHIA) (Required Upon Hire), or Registered Health Information Technologist (RHIT) (Required Upon Hire)

🏝️ Benefits

• Annual training on the use of Protected Health Information (PHI)

• Health insurance

• Opportunities for professional development

• Paid time off

• Options for remote work