Clinical Documentation Integrity Specialist I

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

📋 Description

• Perform concurrent reviews of selected patient health records to assess medical documentation.

• Ensure clinical documentation is clear, complete, consistent, and accurate.

• Implement the query process to accurately reflect severity of illness, risk of mortality, comorbidities, length of stay, principal diagnosis, and POA status.

• Complete reconciliation to guarantee precise coding.

• Cultivate and sustain collaborative relationships with healthcare providers and team members, including education and follow-up efforts.

• Keep abreast of changes in coding guidelines, treatment methodologies, clinical disease indicators, and compliant query policies.

• Act as a resource for colleagues, providers, and support departments.

• Assign a working DRG to facilitate discharge planning and CDI utilization for the healthcare team.

• Undertake additional responsibilities as required.

⛳️ Requirements

• Associate degree in Nursing, Health Information Management, or a related discipline.

• Minimum of two (2) years of experience in adult medical/surgical/critical care/ER/PACU nursing, coding, or a related field.

• Possession of RHIA, RHIT, CCS, CIC certification, or licensure in a relevant area of study.

• Current RN compact/multistate license recognized by the NCSBN Compact State, or an RN license valid in the state where the team member is employed.

• Proficient computer skills.

• Strong communication abilities with a capacity to engage effectively with providers.

• General knowledge of IPPS, ICD-10 Coding, MS-DRG/APR-DRG, and HCPCS coding systems is preferred.

🏝️ Benefits

• Comprehensive health insurance options.

• Retirement savings plan with employer matching.

• Opportunities for professional development and continuing education.

• Paid time off and flexible scheduling.

• Supportive work environment focused on team collaboration.