Clinical Documentation Integrity Specialist – Inpatient

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

📋 Description

• Evaluate inpatient medical records to ensure they are complete and accurate, particularly regarding severity of illness and mortality risk.

• Facilitate effective communication with healthcare professionals to recommend additional documentation as necessary.

• Collaborate closely with Health Information Management (HIM) coding personnel to verify that discharge diagnoses and co-morbidities are accurately documented.

• Perform concurrent reviews of medical records and record findings on Clinical Documentation Specialist (CDS) worksheets.

• Identify primary and secondary diagnoses, procedures, and quality indicators.

• Clarify documentation when required and promote accurate patient records.

• Utilize monitoring tools to assess program progress and communicate findings.

• Provide education to staff on enhancing documentation and ensure compliance.

• Collaborate with the healthcare team to streamline clinical documentation processes.

⛳️ Requirements

• An Associate's Degree in Health Information Management or a related discipline from an accredited institution.

• Certification in RHIT or RHIA, in addition to CCDS or CDIP credentials.

• For Nurses: An Associate's degree and a minimum of 3 years of experience in an acute care environment.

• For all other clinical disciplines: An Associate's degree in their specific field from an accredited college or university.

• A foreign medical graduate (MD) with CDI certification of CCDS and/or CDIP may substitute for a Kansas RN license.

• At least 3 years of experience in Clinical Documentation, Case Management/Utilization Review, or Critical Care.

• Licensed Registered Nurse (LRN) - Single State or Multi-State - State Board of Nursing certification.

• Must possess CCDS or CDIP certification, or be a foreign medical graduate (MD) with CDI certification.

🏝️ Benefits

• The health system is committed to being an equal employment opportunity employer.

• Offers reasonable accommodations to qualified individuals with disabilities.