RN Clinical Documentation Improvement Specialist

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

📋 Description

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

• Review clinical documentation and pinpoint areas for enhancement in medical record accuracy.

• Execute mortality assessments, PSI evaluations, and other specialized CDI initiatives.

• Facilitate and secure physician documentation that underlines illness severity, anticipated mortality risk, and care complexity.

• Initiate interactions with physicians through queries and participation in rounding activities.

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

• Implement hospital coding systems, policies, federal and state reimbursement guidelines, along with Coding Clinic Guidelines.

• Assign working DRGs and monitor records throughout hospitalization for specific DRGs.

• Collaborate with coders, auditors, quality improvement teams, and various stakeholders.

• Keep abreast of the latest clinical documentation standards, coding regulations, and compliance requirements.

⛳️ Requirements

• Associate’s Degree in Nursing.

• Bachelor's Degree in Nursing is preferred.

• A valid US RN license is mandatory.

• Experience in Front Line CDI within an acute care hospital setting.

• 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.

• Proficient in CDI methodologies, coding, and documentation standards that pertain to quality outcomes, medical record accuracy, and reimbursement practices.

• Understanding of CMS rules and regulations.

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

🏝️ Benefits

• Competitive benefits package.

• Opportunities for continuous learning, cross-group collaboration, and exploration of new career avenues.

• Engaging work that makes a difference in the communities served globally.