Clinical Documentation Specialist

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

📋 Description

• Perform thorough secondary clinical chart assessments to pinpoint potential missed opportunities for documentation clarification.

• Partner with Coders, Coding Educators, Coding Quality Auditors, Case Managers, the Quality Department, and Healthcare Providers.

• Carry out daily, concurrent reviews of inpatient records in designated units.

• Ensure that complete and accurate documentation from physicians and clinicians is available at discharge for timely, compliant coding.

• Review daily admissions and assign initial codes for a working DRG.

• Enter data into CDI software for initial and follow-up case reviews or worksheets, including code and DRG assignments, and forward to the Program Assistant.

• Adjust the working DRG as needed when documentation or physician query responses warrant a change.

• Notify the CDI Coordinator when the volume of daily reviews necessitates assignment modifications.

• Initiate compliant physician queries when documentation is unclear, ambiguous, or lacking.

• Follow up with physicians to secure prompt responses to queries, utilizing AHIMA practice briefs as guidance.

⛳️ Requirements

• Bachelor's degree.

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

• At least 4 years of experience in providing direct patient care to acute and chronically ill patients in inpatient settings, critical care, or emergency departments, or substantial medical-surgical experience.

• A minimum of 2 years of prior CDI experience.

• Knowledge of encoders and DRG assignment.

• Maintain up-to-date knowledge of official coding guidelines and coding clinics.

• CCDS or CDIP certification is preferred.

• Experience in ED/Critical care or case management; or inpatient acute care (referral hospital) is preferred.

• Strong critical thinking abilities.

• Excellent interpersonal skills.

• Robust clinical knowledge base.

• Preferred experience in Coding, Case Management, or Utilization Review.

• Strong understanding of disease processes.

• Ability to demonstrate critical thinking, analytical skills, and problem-solving capabilities.

• Comprehensive knowledge of medical terminology, anatomy, physiology, microbiology, and disease processes.

• Capacity to engage with physicians in challenging scenarios.

• Proficient typing and computer skills.

• Familiarity with EHR systems, CDI software systems, and encoders.

🏝️ Benefits

• Medical, Rx, Dental & Vision Insurance.

• Personal and Family Sick Time & Company Paid Holidays.

• Position may qualify for a discretionary variable incentive bonus.

• Parental Leave.

• 401(k) Retirement Plan.

• Basic Life & Supplemental Life Insurance.

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

• Short-Term & Long-Term Disability coverage.

• Tuition Reimbursement, Personal Development & Learning Opportunities.

• Skills Development & Certifications.

• Employee Referral Program.

• Corporate Sponsored Events & Community Outreach.

• Emergency Back-Up Childcare Program.

• Flexible benefits package.