Clinical Documentation Integrity Specialist I, Relief

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

📋 Description

• Conduct concurrent and retrospective reviews of clinical documentation for inpatient and/or outpatient medical records.

• Identify areas for enhancing the quality and thoroughness of clinical documentation.

• Facilitate and secure physician documentation that supports the severity of illness, anticipated risk of mortality, care complexity, coding, and outcomes.

• Initiate medical record reviews within 24 to 48 hours of patient admission and monitor targeted records within at least 48 hours.

• Conduct follow-up reviews to ensure that clarifications are properly documented in the medical record.

• Apply coding policies, reimbursement guidelines, Coding Clinic Guidelines, MS-DRGs, APR-DRGs, HCCs, ICD-10-CM/PCS, and AMA CPT conventions to assign working and final DRGs.

• Collaborate with inpatient coding staff to guarantee accuracy in diagnostic and procedural data as well as documentation completeness.

• Advise and guide clinical providers on documentation, coding concepts, and query procedures.

• Maintain collaborative relationships with assigned departments and service lines.

• Query physicians regarding unclear, missing, conflicting, or abnormal clinical information, including through face-to-face interactions and rounding.

• Support CDI service line teams and leadership with documentation evaluations and improvement initiatives.

• Perform continuous documentation analysis and submit clarifications or queries to address gaps and inconsistencies.

• Assist colleagues and leadership in understanding variances and CDI-related challenges.

• Suggest enhancements to documentation tools, provider engagement, and related processes.

• Reconcile query and non-query impacts within CDI data-entry systems.

• Manage projects related to clinical documentation initiatives, scope expansion, and opportunity identification.

⛳️ Requirements

• Bachelor’s degree in Nursing, Medicine, Health Information Management, or a closely related field, or an equivalent combination of education and experience.

• Five (5) years of progressively responsible and directly related inpatient clinical experience.

• 0–2 years of CDI-related work experience.

• ICU/ED and Academic Medical Center experience is preferred.

• Experience in case management, utilization review, and/or direct provider interaction is preferred.

• Familiarity with AHIMA and ACDIS Ethical Standards.

• Knowledge and application of CMS coding guidelines and methodologies, MS-DRGs, APR-DRGs, HCCs, ICD-10-CM/PCS, and AMA CPT coding guidelines and conventions.

• Ability to remain updated with CMS rules and regulations.

• Capability to analyze problems, data, and reporting systems while developing solutions or process enhancements.

• Ability to exercise judgment, make informed decisions, organize and prioritize tasks, multitask, adapt to shifting priorities, and meet deadlines.

• Ability to manage projects involving multidisciplinary teams and workflows.

• Ability to create, deliver, and oversee clinical documentation education content.

• Proficiency in Microsoft Office Suite, including word processing, spreadsheets, and presentation software.

• Knowledge of analytical research procedures and methods.

• Ability to conduct testing, data auditing, and implementation of CDI and coding software or documentation processes.

• Ability to develop and maintain collaborative relationships with physicians and clinical professionals.

• Strong verbal and written communication skills in English; mastery of verbal and written English communication.

• Beginning to intermediate proficiency in MS Office Suite; intermediate to advanced proficiency may also be considered.

• Some experience with an encoder and/or electronic health record systems; exposure to or experience with 3M encoder and/or Epic electronic health record systems.

• RN state licensure and/or compact state licensure is preferred.

🏝️ Benefits

• This is a non-benefitted role (no employer benefits are specified).

• Remote work arrangement.