Clinical Documentation Specialist

This is a fully remote position, open to applicants in California, +9 more states.

📋 Description

• Conducts both concurrent and retrospective reviews of inpatient medical records based on clinical evaluation.

• Guarantees that documentation accurately represents the quality of care, severity of illness, and risk of mortality, facilitating compliant coding, reimbursement, quality reporting, and initiatives to prevent denials.

• Proactively reaches out to physicians or other healthcare professionals to clarify procedures and diagnoses, ensuring appropriate documentation.

• Performs both initial and follow-up case reviews.

• Submits compliant provider queries as necessary to clarify documentation of pertinent diagnoses, procedures, clinical indicators, present-on-admission status, acuity, specificity, and treatment in alignment with ACDIS/AHIMA compliant query guidance and organizational policies.

• Utilizes expertise in ICD-10-CM/PCS Official Guidelines for Coding and Reporting, AHA Coding Clinic, MS-DRG/APR-DRG methodology, CC/MCC capture, SOI/ROM, and quality indicators to support an accurate working DRG in collaboration with the Coding/HIM department.

• Fosters collaboration with the Coding/HIM team to ensure the accuracy of principal diagnosis, procedures, and thorough documentation to ascertain the working and final DRG, severity of illness, and risk of mortality.

• Acts as a bridge between clinical and coding teams.

• Actively participates in educational delivery to providers through extensive one-on-one interactions.

• Applies critical thinking and clinical reasoning skills to identify, clarify, and query accurate documentation representation to reflect the patient's appropriate clinical status, impacting quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending.

⛳️ Requirements

• Bachelor's degree in Nursing, Health Information Management, healthcare administration, or a related healthcare field is preferred.

• An associate degree/diploma, allied health education, or equivalent professional credential may be accepted with proven CDI, clinical, coding, or HIM experience.

• Preferred 2-5 years of experience in acute care clinical settings, inpatient coding, HIM, quality, utilization review/case management, or revenue cycle.

• Knowledge of inpatient CDI and familiarity with IPPS, MS-DRGs, CC/MCCs, SOI/ROM, HAC/PSI, and denials prevention is preferred.

• A current unrestricted RN, LPN/LVN, or other applicable clinical license is required only if the candidate is hired under that clinical credential.

• Consideration may be given to candidates with RHIA, RHIT, CCS, CCDS, CDIP, MD/DO/MBBS, foreign medical graduate, or other relevant healthcare/coding credentials supported by demonstrated clinical documentation and coding knowledge.

• CCDS or CDIP certification is preferred and encouraged; experienced CDI Specialists should aim to obtain CCDS or CDIP within 24 months of meeting eligibility criteria or hiring, unless otherwise approved by CDI leadership.

🏝️ Benefits

• Competitive salary and comprehensive benefits package.

• Opportunities for professional growth and career advancement.

• Supportive work environment with a collaborative team dynamic.

• Comprehensive healthcare coverage.

• Retirement savings options.

• Paid time off and flexible scheduling arrangements.

• Student loan repayment assistance program.