Clinical Documentation Specialist – CDI

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

📋 Description

• Assess inpatient medical records for accuracy, completeness, and adherence to compliance standards.

• Achieve and maintain an accuracy rate of 98%.

• Recognize opportunities for clarifying diagnoses and procedures.

• Initiate compliant physician queries to resolve conflicting documentation.

• Work collaboratively with coding staff to ensure precise coding and DRG assignment.

• Track documentation trends associated with mortality and quality indicators.

• Conduct clinical validation reviews for high-risk conditions.

• Uphold productivity and quality benchmarks.

• Engage in multidisciplinary rounds and initiatives aimed at improving documentation.

⛳️ Requirements

• Possession of a valid Registered Nurse license along with a bachelor’s degree or higher (must be completed and verified prior to employment) AND a minimum of seven (7) years of Nursing experience AND five (5) years of experience in an inpatient acute care environment OR a High School Diploma/GED accompanied by eleven (11) years of experience in an inpatient acute care setting.

• Familiarity with auditing practices, ICD 10, PCS guidelines, quality initiatives, and MS-DRG and APR DRG methodologies.

• Strong clinical knowledge and its application to coding.

• Experience with CCDS, CCS, or CDIP, with seven (7) years of clinical documentation/DRG validation experience.

🏝️ Benefits

• Medical, Dental & Vision coverage.

• Health Savings Accounts.

• Flexible Spending Accounts for Health Care & Dependent Care.

• Disability Benefits.

• Life Insurance.

• Voluntary Benefits.

• Paid Absences.

• Retirement Benefits.