Registered Nurse, Clinical Documentation Integrity Specialist

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

📋 Description

• Conduct clinical chart assessments to verify the accuracy of documentation in accordance with established clinical criteria.

• Engage with providers to resolve any missing, unclear, or contradictory documentation while adhering to ACDIS/AHIMA guidelines.

• Partner with providers and healthcare teams to enhance risk adjustment and quality metrics.

• Provide education to providers on best practices for documentation, HCC coding, and medical necessity through individual and group training sessions.

• Develop and present materials that support CMS, HHS, and regulatory compliance for risk adjustment coding.

• Monitor and report on documentation trends to CDI leadership, identifying areas for improvement.

• Carry out other assigned responsibilities as needed.

⛳️ Requirements

• An Associate's degree paired with a current active clinical license (RN) is required.

• A minimum of 3 years of experience in clinical documentation improvement, coding, or a related field is required.

• At least 1 year of experience collaborating with advanced practice providers and both clinical and non-clinical staff is required.

• Preferred: Over 5 years of clinical experience as a Registered Nurse (adult-geriatric or family).

• Must possess a current active clinical license (RN) without restrictions in the state of residence.

• CCDS-O or CDIP is required or must be obtained within six months of hire.

• CRC is required or must be obtained within one year of hire.

• Strong clinical foundation in evidence-based medicine, particularly in chronic disease management and prevention.

• Familiarity with ICD-10 coding, documentation requirements, and risk adjustment is essential.

• Knowledge of compliant query writing and processes is necessary.

• Capability to conduct comprehensive reviews of 20–30 medical records each day.

• Technical proficiency with EMR systems is expected.

• Competency in Excel, Outlook, Teams, PowerPoint, and Word is required.

• Excellent written and verbal communication skills are essential for the role.

• Must be able to lift 5–50 lbs unassisted and perform tasks involving standing, sitting, stooping, walking, stretching, reaching, and utilizing a full range of body movements.

• Manual dexterity and the ability to operate a computer keyboard and peripherals are necessary.

🏝️ Benefits

• 401k matching.

• Comprehensive healthcare coverage.

• Competitive total rewards package.

• Reasonable accommodations for qualified individuals with disabilities.

• Remote work opportunities.

• Travel for in-person training sessions 2–4 times per year.