Clinical Documentation Integrity Specialist I, Relief, Non-benefitted

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

📋 Description

• Perform concurrent and retrospective evaluations of both inpatient and outpatient medical records.

• Assess clinical documentation and pinpoint areas for enhancing documentation quality.

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

• Initiate reviews of medical records within 24 to 48 hours of patient admission.

• Monitor selected medical records to ensure compliance with documentation standards.

• Conduct follow-up reviews to confirm that clarifications are accurately documented.

• Utilize coding policies, reimbursement guidelines, and Coding Clinic Guidelines to assign working DRGs.

• Collaborate with inpatient coding teams to guarantee the accuracy of diagnostic and procedural data as well as complete supporting documentation.

• Provide guidance and advice to clinical providers regarding documentation, coding concepts, and query processes.

• Engage with physicians and initiate queries for any ambiguous, missing, or conflicting information.

• Contribute to initiatives aimed at enhancing provider engagement and documentation integrity.

• Analyze documentation performance and submit queries or clarifications to address identified gaps and inconsistencies.

• Support colleagues and leadership in overcoming documentation and CDI-related challenges and conducting variance analysis.

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

• Reconcile the impact of queries and non-queries within CDI data entry systems.

• Oversee projects related to clinical documentation initiatives and assess potential scope expansion or opportunities.

⛳️ Requirements

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

• A minimum of five years of progressively responsible and directly related inpatient clinical experience.

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

• Experience in ICU/ED and academic medical centers is preferred.

• Preferred experience in case management, utilization review, and/or direct interaction with providers.

• Familiarity with AHIMA and ACDIS Ethical Standards.

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

• Capability to analyze problems and comprehend regulatory and reimbursement implications.

• Understanding of local, state, and federal regulatory requirements pertinent to the functional area.

• Ability to analyze data, draw valid conclusions, and provide sound recommendations.

• Skill in communicating complex concepts to individuals outside of CDI or Revenue Cycle expertise.

• Competence in managing, organizing, prioritizing, multitasking, adapting to changing priorities, and meeting deadlines.

• Experience in managing projects that involve multidisciplinary teams and workflows.

• Ability to deliver concise reports regarding activities and outcomes.

• Proficiency in creating, delivering, and overseeing educational content associated with clinical documentation integrity.

• Proficient in Microsoft applications, including word processing, spreadsheets, and presentation software.

• Knowledge of analytical research methods and procedures.

• Ability to evaluate reporting systems and implement process and procedural improvements.

• Skill in testing, data auditing, and implementing CDI and coding software or documentation processes.

• Capacity to develop and sustain collaborative relationships with physicians and other clinical professionals.

• Excellent command of verbal and written English communication.

• Intermediate proficiency in Microsoft Office Suite.

• Some familiarity with encoder systems and/or electronic health record systems.

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

🏝️ Benefits

• Option for remote work.

• Part-time work schedule.

• This position is non-benefitted (no benefits provided).