Senior Clinical Documentation Improvement Specialist

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

📋 Description

• Perform evaluations of inpatient medical records to pinpoint missing, unclear, or incomplete documentation.

• Relay the need for supplementary documentation to relevant clinical providers and/or coding personnel.

• Ensure that the additional documentation is completed promptly.

• Collaborate with coding, quality, compliance, medical staff, utilization review/case management, and other relevant departments.

• Enhance the quality of provider documentation.

• Support initiatives aimed at improving documentation quality across all caregivers.

• Offer data reports and educational assistance on necessary documentation elements to inpatient healthcare providers.

• Assist with special projects and committees.

• Mentor junior CDI Specialists.

• Execute duties in alignment with Mercy’s mission, values, and Service Standards.

⛳️ Requirements

• RN, BSN, RHIA, RHIT, CCS, CPC, CIC, CCDS, or CDIP certification.

• Minimum of 3 years of CDI experience, alongside at least 1 year in nursing, inpatient coding, UM, CM, Quality, or a related field.

• Proficient in the role of Clinical Documentation Specialist.

• Capable of detailed data analysis and presenting complex data or education to providers individually or in group settings.

• Exceptional critical thinking and reading comprehension skills.

• Strong clinical knowledge with the ability to identify diagnoses based on clinical data.

• Comprehensive understanding of disease processes and clinical outcomes.

• Familiarity with Excel, Word, and PowerPoint.

• Advanced knowledge of healthcare regulations, including reimbursement, documentation requirements, and quality measures.

• Skilled in record review with the ability to interpret clinical data.

• Excellent written and verbal communication skills, with comfort speaking in groups.

• Ability to plan and organize workflow effectively to meet deadlines.

• Strong computer skills, including typing proficiency.

• Capability to generate reports using various formats and software.

• Ability to interpret data reports and convey findings to medical staff committees as necessary.

• Capacity to build collaborative working relationships with diverse groups, medical staff, and healthcare disciplines.

• Ability to mentor junior CDI Specialists.

• Flexibility to work schedules that accommodate provider rounding times and required medical staff presentations.

• Ability to operate with minimal supervision, function effectively in a high-stress environment, maintain confidentiality of sensitive information, and foster team building.

• Preferred: 3–5 years of CDI experience.

• Preferred: CCDS from ACDIS or CDIP from AHIMA.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Tuition support.

• Matched retirement plans for team members working 32+ hours per pay period.