Clinical Documentation Specialist, CDI

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

📋 Description

• Conduct concurrent and/or retrospective reviews of inpatient medical records to ensure documentation is accurate, complete, and compliant.

• Achieve and maintain an accuracy rate of 98%.

• Identify areas for improvement regarding diagnoses, procedures, POA indicators, severity of illness, risk adjustment, and clinical validation.

• Initiate compliant physician queries for any conflicting, incomplete, or vague documentation.

• Work collaboratively with coding staff to ensure accurate ICD-10-CM/PCS coding and proper MS-DRG/APR-DRG assignment.

• Track documentation trends concerning mortality, quality indicators, HACs, and PSIs.

• Perform clinical validation reviews for conditions such as sepsis, respiratory failure, encephalopathy, malnutrition, acute kidney injury, and other high-risk scenarios.

• Maintain a query rate of 35–40%, reviewing 20–25 cases daily while achieving 98% accuracy.

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

• Contribute to denial prevention through initiatives focused on documentation integrity.

• Stay updated with CMS, ICD-10, AHA Coding Clinic, and organizational compliance standards.

• Adhere to corporate policies, procedures, and security protocols.

⛳️ Requirements

• Possession of a valid Registered Nurse license.

• A Bachelor’s degree or higher, verified and completed before commencement.

• A minimum of seven (7) years of nursing experience.

• At least five (5) years of experience in an inpatient acute care environment.

• Proven experience in auditing practices, ICD 10, PCS guidelines, quality initiatives, and methodologies for MS-DRG and APR DRG.

• Clinical knowledge applicable to coding.

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

• Familiarity with telecommuting, EMRs, electronic tools, and current chart auditing competencies.

• Knowledge of the Solventum HIS software suite, particularly 360 Encompass.

• Proficiency in Microsoft Word, Excel, PowerPoint, and other Microsoft Office applications.

• Exceptional verbal, written, presentation, analytical, and organizational skills.

• Must have legal authorization to work in the country of employment without the need for employment visa sponsorship.

🏝️ 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.

• Company-paid travel arrangements for on-site onboarding and related expenses.

• Possible relocation assistance may be provided.