Clinical Documentation Specialist – III Inpatient

This is a fully remote position, open to applicants in Virginia, +1 more state.

📋 Description

• Strategically manage the integration of service lines across the health system.

• Conduct focused and second-level reviews.

• Support the CDI Manager in planning, executing, delivering, collecting data, reporting, and managing assigned projects.

• Collaborate with the CDI Educator/Manager to provide education for providers.

• Act as a subject matter expert for system service lines and participate in related revenue integrity meetings.

• Identify and document principal and secondary diagnoses and procedures while assigning working DRGs.

• Perform initial concurrent reviews and ongoing re-reviews for selected admissions.

• Recognize documentation clarification needs through quality audits and initiate queries to physicians, nurses, or patient care coordinators.

• Educate providers and staff regarding documentation issues, guidelines, and unresolved queries.

• Advocate for compliance with CMS, Medicare documentation, coding, and billing regulations.

• Engage in service assessment, improvement, and regulatory compliance procedures, and report findings.

• Work with Quality to ensure documentation meets standards for quality initiatives and outcome reporting.

• Gather, analyze, and submit precise clinical documentation reports.

• Collaborate with Coding Specialists on issues related to documentation, providers, and queries.

• Mentor and provide guidance to Level I and II CDI Specialists.

⛳️ Requirements

• Certification in one of the following: Certified Documentation Integrity Practitioner (CDIP) through AHIMA; Certified Clinical Documentation Specialist (CCDS) through ACDIS; or Certified Documentation Expert Inpatient (CDEI) through AAPC.

• Three years of experience in inpatient acute care coding OR three years of clinical RN experience in an inpatient acute care setting OR three years of clinical LPN experience in an inpatient acute care setting.

• Five years of experience in Clinical Documentation Integrity.

• Exceptional written, verbal, and interpersonal communication skills.

• Understanding of provider healthcare compliance, revenue cycle operations, and auditing methods.

• Capability to meet quality and productivity benchmarks.

• Ability to maintain focus and accuracy amidst constant interruptions.

• Capacity to prioritize responsibilities and adapt to changes in the workplace and assignments.

• Strong organizational and time management abilities.

• Familiarity with anatomy, physiology, and medical terminology.

• Proficient analytical and problem-solving skills.

• Proficient in office software applications.

• Ability to work autonomously with minimal supervision.

• Ability to sit for extended periods, with normal visual and hearing acuity and manual dexterity to operate computer and office equipment.

🏝️ Benefits

• Full-time work schedule.

• Exempt position.

• Remote work arrangement.