Clinical Documentation Specialist – CDI

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

📋 Description

• Applies advanced clinical and coding knowledge to ensure the integrity of clinical documentation in the roles of reviewer, educator, and consultant.

• Ensures the overall quality, completeness, accuracy, and integrity of medical record documentation through thorough record evaluations.

• Engages extensively with physicians and other healthcare team members to attain appropriate clinical documentation that supports code assignment, medical necessity, severity of illness, risk of mortality, and level of services provided to all patients.

• Involved in the creation and presentation of educational sessions for healthcare providers and team members.

⛳️ Requirements

• Associate/Diploma Degree in Nursing or Health Information Technology (HIT) or an advanced degree in the nursing or medical field such as MD, DO, NP/APN, or PA.

• If lacking a college degree, a minimum of 3 years of experience as an inpatient coder or clinical documentation specialist is required.

• Preferred certifications or licenses include: Current Registered Nurse License, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS), and Certified Documentation Improvement Professional (CDIP).

• Preferred experience includes Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, Physician Assistant (PA), Nurse Practitioner/Advanced Practice Nurse (NP/APN), medical school graduate, or as an inpatient coder.

🏝️ Benefits

• Health insurance

• 401(k) matching

• Paid time off

• Professional development opportunities