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

📋 Description

• Conduct inpatient chart evaluations to ascertain appropriate DRG classifications.

• Verify that medical record documentation aligns with clinical care, severity of illness, risk of mortality, Case Mix Index, and mortality ratings.

• Collaborate with physicians, nurses, and ancillary staff to clarify documentation.

• Record findings in Carle CDI software and update the status of encounters.

• Coordinate efforts with physicians, nurses, ancillary hospital staff, and Health Information Management coding personnel.

• Identify and document principal and secondary diagnoses and procedures.

• Assign working DRGs and perform second-level reviews on selected inpatient cases.

• Adhere to the query process and escalate issues as necessary.

• Provide CDI training to colleagues and healthcare providers.

• Review DRG denials and prepare appeal letters when required.

• Participate in mandatory and ongoing educational sessions.

• Follow established workflows in EPIC and CDI software, reporting issues to the supervising leader.

• Engage in testing software upgrades as needed.

⛳️ Requirements

• A minimum of 2 years of experience in Clinical Documentation.

• At least 2 years of experience in Nursing or as a Medical Doctor (MD).

• Possession of Registered Health Information Administrator (RHIA) certification, or a Licensed Registered Professional Nurse (RN) within 6 months if licensed in another state.

• Illinois RN licensure through the Illinois Department of Financial and Professional Regulation (IDFPR), if applicable.

• An Associate's Degree in Nursing, an Associate's Degree in Health Information Management, or a Doctorate degree in Medicine.

• 2 years of CDI experience.

• 2 years of clinical bedside experience.

• Ability to work occasional weekends.

• Ability to adhere to the Monday to Friday 8 AM to 5 PM schedule.

🏝️ Benefits

• Comprehensive benefits package.

• Equal opportunity employment.

• Opportunities for growth and lifelong career development.