RN Clinical Documentation Improvement Specialist

This is a fully remote position, open to applicants in Alabama, +5 more states.

📋 Description

• Perform concurrent and retrospective reviews of inpatient medical records based on clinical criteria.

• Assess clinical-service documentation to pinpoint areas for enhancing medical record quality.

• Execute mortality reviews, PSI reviews, and other targeted reviews as directed by CDI leadership.

• Support and obtain physician documentation that reflects the severity of illness, anticipated mortality risk, and care complexity.

• Initiate engagement with physicians via the query process and/or by participating in physician rounding.

• Provide education to physicians and staff regarding documentation requirements, coding standards, and reimbursement policies.

• Assign working DRGs and review patient records during hospitalization to ensure coding precision.

• Collaborate with coders, auditors, quality improvement teams, and other relevant stakeholders to address documentation challenges.

• Take part in documentation improvement initiatives and both formal and informal educational programs.

• Keep updated on clinical documentation standards, coding regulations, and compliance requirements.

⛳️ Requirements

• Associate’s Degree in Nursing is mandatory; a Bachelor’s Degree in Nursing is preferred.

• An active US RN license is required.

• Experience in front line CDI within an acute care hospital setting.

• A minimum of three to five years of recent clinical experience in medical-surgical, ICU, telemetry, and/or emergency department environments.

• Familiarity with electronic medical records (EMR) systems and CDI platforms is essential.

• Highly proficient in CDI practices, coding, and documentation standards related to quality outcomes and reimbursement.

• Understanding of CMS rules and regulations is necessary.

• Clinical experience in ICU, medical-surgical, telemetry, or emergency department settings.

• Ability to navigate Hospital coding code sets, Federal and State coding reimbursement guidelines, and Coding Clinic Guidelines.

🏝️ Benefits

• Annual bonus plan with a target of 5.00%.

• Competitive benefits package offered.

• Opportunities for learning, collaboration across various groups, and exploration of new career paths.

• Chance to engage in meaningful work and contribute positively to the community.