Clinical Documentation Integrity Specialist – FT

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

📋 Description

• Conduct concurrent inpatient documentation reviews to pinpoint areas for enhancing documentation specificity, clinical validation, and coding precision.

• Execute compliant physician queries in line with AHIMA/ACDIS guidelines to resolve conflicting, incomplete, or ambiguous documentation.

• Facilitate accurate ICD-10-CM/PCS coding, MS-DRG/APR-DRG assignment, POA indicators, CC/MCC capture, SOI/ROM, PSIs, HACs, and quality metrics.

• Carry out clinical validation reviews for significant diagnoses, including sepsis, acute respiratory failure, AKI, encephalopathy, malnutrition, and other intricate conditions.

• Work collaboratively with coding, CDI, quality, and physician teams to enhance documentation quality and minimize denials.

• Deliver physician and CDI education based on documentation patterns and audit results.

• Track productivity, quality, and compliance benchmarks while engaging in internal audits and continuous improvement efforts.

• Keep up-to-date with CMS regulations, ICD-10-CM/PCS, Coding Clinic, AHIMA, and ACDIS guidelines.

⛳️ Requirements

• Active RN license or a graduate of an accredited medical program (MD, DO, MBBS, NP, PA, or equivalent clinical background).

• CCDS or CDIP certification is mandatory.

• A minimum of 5 years of concurrent inpatient CDI experience in an acute care hospital setting.

• Extensive knowledge of MS and APR-DRG reimbursement, ICD-10-CM/PCS, clinical validation, and compliant query practices.

• Proficiency with Epic, Cerner, Solventum 360, Iodine, SmarterDx, or similar CDI platforms.

🏝️ Benefits

• Medical, dental, and vision benefits effective the first of the month following the date of hire.

• 401k benefits along with paid holidays and PTO/personal time.