Clinical Documentation Specialist

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

📋 Description

• Enhance the overall quality and completeness of clinical documentation by conducting admission and continued-stay reviews in accordance with CDMP guidelines.

• Facilitate changes to clinical documentation to accurately represent patient severity and support appropriate DRG-based reimbursement.

• Perform follow-up reviews and ensure that clarifications are documented in patient medical records.

• Collaborate with physicians during patient stays to gather necessary documentation and provide educational support.

• Refer concerns regarding quality, patient safety, utilization, and medical necessity to CDI leadership, nursing, case management, or Utilization Review.

• Compose compliant, non-leading clinical documentation queries.

• Monitor documentation against core measure quality indicators and address any instances of non-compliance.

• Work in partnership with physicians, nursing staff, case managers, coding staff, and CDI team members.

• Assign working DRGs, update DRG worksheets, and finalize diagnoses in collaboration with attending physicians.

• Provide education to various audiences on clinical documentation, coding, reimbursement, and performance methodologies.

• Analyze DRGs to enhance knowledge, performance, payment recovery, cost containment, and revenue generation.

• Organize daily reviews, manage schedules and workloads, and ensure compliance with deadlines and productivity standards.

• Engage in special projects and perform other assigned responsibilities.

⛳️ Requirements

• Active RN Licensure in the State of Georgia.

• Associate's Degree.

• A minimum of five (5) years of experience in professional nursing practice.

• Demonstrated proficiency in critical care or medical-surgical nursing.

• Exceptional observation skills, analytical thinking, problem-solving capabilities, and both written and verbal communication skills.

• Familiarity with DRG coding optimization strategies and clinical documentation requirements is advantageous.

• Strong professional interpersonal skills.

• Proficient computer skills and the ability to work independently.

• Knowledge of ICD10 coding conventions, anatomy and physiology, medical terminology, MSDRG reimbursement, and coding software, preferably 3M 360 Encompass.

• Leadership abilities.

• Must comply with the requirements outlined in the Remote Agreement.

• Capability to read, write, reason, communicate verbally, keyboard, and drive.

🏝️ Benefits

• Opportunity for remote work, subject to maintaining the conditions outlined in the Remote Agreement.

• Equal Opportunity Employer.