Clinical Documentation Specialist I

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

📋 Description

• Educate providers and clinicians to ensure that medical record documentation accurately reflects patient conditions and treatments.

• Conduct reviews for appropriate DRG, APC, and HCC assignments, as well as the severity of illness and risk of mortality.

• Identify principal diagnoses, qualifying secondary diagnoses, impactful procedures, and appropriate working DRGs for inpatient cases.

• Engage with providers through queries to achieve diagnostic specificity and present-on-admission status.

• Comply with documentation and coding standards.

• Maintain comprehensive records of reviews and query activities using CDI software.

• Utilize CDI software tools to carry out assigned reviews and select working MS DRG and APR DRG.

• Achieve daily targets for reviews, queries, and query responses.

• Provide guidance to CDS staff regarding procedures, processes, and coverage determinations as needed.

• Participate in educational sessions for physicians, advanced practice providers, and clinical ancillary staff.

• Conduct reviews of outpatient medical records across various settings, including provider offices, physician- and hospital-owned clinics, ASCs, and Emergency Departments.

• Apply clinical expertise to assess documentation, chronic disease processes, medications, diagnostic information, and treatment plans for accurate coding.

• Train providers on documentation and disease process identification to facilitate precise coding and billing.

⛳️ Requirements

• High School Diploma/GED or equivalent qualification.

• Minimum of five years’ experience as a clinical nurse, inpatient or outpatient coder, or two years as a Clinical Documentation Integrity Specialist.

• Proficient in utilizing department CDI software.

• Skilled in using reporting functions to create materials for meetings and presentations.

• An Associate’s Degree in a healthcare-related field is preferred.

• Current Registered Nurse (RN) license in the state of employment is preferred.

• Preferred experience in inpatient or outpatient coding with ICD10-CM, CPT, HCC, and HCPCS.

• Strong background in Med Surg, ICU, or ER is preferred.

• Knowledge of PSI and CDI is preferred.

• Familiarity with physician documentation in both inpatient and outpatient environments is preferred.

• Understanding of inpatient or outpatient payment methodologies is preferred.

• Certification as a Clinical Documentation Specialist (CCDS or CCDS-O) from ACDIS within one year of hire is preferred.

• Ability to fulfill CEU requirements to maintain license and certification.

• Physical capability to stand, walk, sit, lift, and carry up to 25 lbs.

• Close, distant, and color vision capabilities.

• Manual dexterity for handling records and operating a PC.

• Compliance with controlled substance testing and annual influenza vaccination program or an approved exemption.

🏝️ Benefits

• Remote work hours from 8:00 a.m. to 5:00 p.m.

• Commitment to equal opportunity employment.

• Drug-free workplace environment.

• Annual influenza vaccination program or approved exemption.

• Provision of personal protective equipment (PPE) as necessary.