Clinical Documentation Specialist

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

📋 Description

• Perform thorough secondary clinical chart reviews to uncover potential areas for documentation improvement.

• Work collaboratively with Coders, Coding Educators, Coding Quality Auditors, Case Managers, the Quality Department, and Providers.

• Execute daily, concurrent reviews of inpatient records within designated units.

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

• Analyze daily admissions and carry out initial code assignments for a working DRG.

• Complete data entry in CDI software for initial and follow-up case reviews or worksheets, including code and DRG assignments.

• Revise the working DRG when documentation or physician query responses justify a modification.

• Communicate with the CDI Coordinator regarding the volume of review assignments.

• 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 a reference.

⛳️ Requirements

• A University Degree is required, along with a minimum of 2-4 years of relevant experience; some positions may necessitate a graduate-level education such as a Master’s or Doctorate degree (relevant experience may substitute for formal education or advanced degree).

• Must possess one of the following: RN, MD, or MD Equivalent (MBBS), CCS.

• At least 4 years of experience delivering direct patient care to acute and chronically ill patients in inpatient environments, including critical care, ED, or substantial med-surg experience, or equivalent prior experience.

• A minimum of 2 years of prior CDI experience is required.

• Familiarity with encoder and DRG assignment is essential.

• Maintain a current understanding of official coding guidelines and coding clinics.

• CCDS and CDIP certifications are preferred.

• Experience in ED/Critical care or case management; or inpatient acute care (referral hospital); should possess strong critical thinking and interpersonal skills along with a robust clinical knowledge base.

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

• Strong clinical comprehension of disease processes is necessary.

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

• Extensive knowledge of medical terminology, anatomy, physiology, microbiology, and disease processes is required.

• Capable of engaging in conversations with physicians in challenging scenarios.

• Proficient typing and computer skills; adept 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.

• Flexible work arrangements.