Clinical Documentation Specialist – III, Inpatient

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

📋 Description

• Oversee the integration of service lines across the health system.

• Conduct focused and secondary reviews.

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

• Partner with the CDI Educator/Manager to enhance provider education.

• Serve as a service line expert, strategically managing the impact of CDI.

• Participate in revenue integrity meetings related to the designated service line.

• 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 via audits and initiate queries with physicians, nurses, or patient care coordinators.

• Provide education to providers and staff on documentation challenges, guidelines, and unresolved queries.

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

• Evaluate and enhance services and regulatory compliance, reporting findings to administrative levels.

• Collaborate with the Quality Department on documentation standards for quality initiatives.

• Gather, analyze, and submit clinical documentation reports reflecting hospital and provider outcomes.

• Collaborate with Coding Specialists to address documentation and query-related issues.

• 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.

• Minimum of three years of inpatient acute care coding experience, or three years of clinical RN experience in an inpatient acute care environment, or three years of clinical LPN experience in an inpatient acute care setting.

• At least five years of experience in Clinical Documentation Integrity.

• Familiarity with healthcare compliance for providers, revenue cycle operations, and auditing techniques.

• Understanding of anatomy, physiology, and medical terminology.

• Proficient in office software applications.

• Strong written, verbal, and interpersonal communication skills.

• Possess analytical and problem-solving abilities.

• Capability to work independently with minimal supervision.

• Ability to meet quality and productivity benchmarks.

• Skill in prioritizing tasks and managing time efficiently.

• Flexibility to adapt to changes in the workplace and work assignments.

• Capacity to maintain focus and accuracy amidst constant interruptions.

• Ability to sit for extended periods.

• Normal visual and hearing acuity.

• Manual dexterity for operating computer and office equipment.

🏝️ Benefits

• Full-time schedule of 40 hours per week.

• Exempt position.

• May require travel.