Clinical Documentation Specialist

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

📋 Description

• The CDI Specialist is tasked with conducting thorough secondary clinical chart reviews to pinpoint potential missed opportunities for clarifying documentation.

• Works closely with Coders, Coding Educators, Coding Quality Auditors, Case Managers, the Quality Department, and Providers to ensure that documentation is clinically appropriate, accurately reflects the severity of illness and mortality risk for patients, and aligns with current CMS or other regulatory standards.

• Performs daily, concurrent reviews of inpatient records within assigned unit(s) to guarantee that complete and accurate physician or clinician documentation is available at the time of discharge for timely, precise, and compliant coding.

• Reviews daily admissions to the assigned unit, executes initial code assignment for a working DRG, and completes CDI software data entry for initial and follow-up case reviews (or worksheets including code and DRG assignment) to be submitted to the Program Assistant.

• Modifies the “working DRG” as documentation or responses to physician queries warrant a change in the DRG assignment.

• Notifies the CDI Coordinator when the volume of daily review assignments is excessively high or low, allowing the CDI Coordinator to help redistribute review assignments among the team.

• Initiates compliant physician queries when documentation is unclear, ambiguous, or lacking, and follows up with the MD for prompt responses to queries (using AHIMA practice briefs as references: “Managing an Effective Query Process,” October 2008 and “Guidance for Clinical Documentation Improvement Programs,” May 2010).

⛳️ Requirements

• Bachelor's degree

• One of the following: RN, MD, or MD Equivalent (MBBS)

• 4+ years of experience providing direct patient care to acute and chronically ill patients in inpatient settings, critical care, ED, or extensive med-surg experience

• 2+ years of prior CDI experience

• Familiarity with encoder and DRG assignment

• Maintain current working knowledge of official coding guidelines and coding clinics

🏝️ Benefits

• Medical, Rx, Dental & Vision Insurance

• Personal and Family Sick Time & Company Paid Holidays

• Position may be eligible for a discretionary variable incentive bonus

• Parental Leave and Adoption Assistance

• 401(k) Retirement Plan

• Basic Life & Supplemental Life

• Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts

• Short-Term & Long-Term Disability

• Student Loan PayDown

• Tuition Reimbursement, Personal Development & Learning Opportunities

• Skills Development & Certifications

• Employee Referral Program

• Corporate Sponsored Events & Community Outreach

• Emergency Back-Up Childcare Program

• Mobility Stipend