RN – Clinical Documentation Integrity Specialist

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

📋 Description

• Conducts reviews of inpatient charts to ascertain the correct DRG assignment and ensure that documentation reflects clinical care, illness severity, and mortality risk.

• Collaborates with physicians, nurses, ancillary staff, and Health Information Management coders to accurately identify and document diagnoses, procedures, and working DRGs.

• Carries out a second-level review of assigned DRGs.

• Delivers education on Clinical Documentation Improvement (CDI) topics to colleagues, providers, and clinicians.

• Analyzes DRG denials and supplies details to the denials team for appeal processes.

• Performs thorough, concurrent, and retrospective evaluations of inpatient accounts.

• Detects absent, vague, or contradictory documentation that could impact DRG assignment, Severity of Illness/Risk of Mortality (SOI/ROM), mortality, Patient Safety Indicators (PSI), quality metrics, and clinical outcomes.

• Creates and distributes compliant, clinically justified queries for physicians.

• Offers guidance and training to providers and clinicians regarding DRG and documentation enhancement opportunities.

• Assists in quality reporting, CDI program development, and adherence to regulatory compliance initiatives.

• Engages in audits, data validation, and performance improvement projects.

• Utilizes EPIC and CDI software workflows, follows up on pending queries, and communicates issues to leadership.

• Acts as an expert in testing upgrades when necessary.

• Attends mandatory educational sessions.

⛳️ Requirements

• Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR).

• Certified Clinical Documentation Specialist (CCDS) within one year - Association of Clinical Documentation Integrity Specialists (ACDIS).

• Certified Coding Specialist (CCS) within one year - American Health Information Management Association (AHIMA).

• Registered Health Information Technician (RHIT) - American Health Information Management Association (AHIMA).

• Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA).

• Licensed Physician (MD) - Illinois Department of Financial and Professional Regulation (IDFPR).

• Doctorate in Medicine.

• College Diploma in Health Information Management.

• College Diploma in Nursing.

• Experience in CDI, coding, or clinical bedside care.

• Strong understanding of ICD-10 guidelines.

• Familiarity with electronic health record (EHR) systems.

• Excellent communication abilities for effective interaction with physicians.

• Advanced comprehension of clinical guidelines, coding updates, and CDI best practices.

• Capability to support documentation processes using clinical knowledge and coding standards.

• Proficiency in utilizing EPIC scoring tools and CDI software.

• Ability to meet production targets and established query turnaround times.

• Commitment to maintaining necessary educational hours for credential re-certification.

🏝️ Benefits

• Comprehensive benefits package.

• Day shift schedule, Monday through Friday.

• No holiday work obligations.

• No on-call duties.

• Opportunities for professional growth and lifelong careers.

• Equal opportunity employment.