Senior Specialist, Clinical Documentation Integrity

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

📋 Description

• The Senior Clinical Documentation Integrity Specialist (CDI) is accountable for reviewing documentation, educating clinicians and other stakeholders, and creating processes to support continuous documentation enhancement and improvement.

• Evaluates key performance indicators.

• Assesses medical records to develop and deliver customized training initiatives for clinicians based on performance evaluations.

• Collaborates with various stakeholders (clinical leadership, revenue cycle, quality team) to establish a cohesive strategy for documentation improvement.

• Conducts documentation reviews at sites with documentation improvement opportunities and/or new locations until coding and documentation are stabilized.

• Designs site-specific provider training as required by chart review outcomes.

• Engages consistently with clinicians and other stakeholders to promote accurate documentation practices aimed at concurrent and ongoing documentation improvement.

• Provides continuous outreach education for clinicians on coding and documentation standards utilizing various formats such as onsite, classroom, telephonic, electronic, and web-based applications.

• Participates in monthly clinician group sessions at the local or regional level.

• Presents performance updates during Practice Operational Review (POR) meetings.

• Organizes and schedules conference calls and site reviews, as well as preparing materials for meetings.

• Assists with ad-hoc requests for site documentation training.

• Records, monitors, and tracks all clinician outreach and training activities.

• Communicates updates regarding changes in coding and documentation policies as well as payor rule modifications to clinicians and other stakeholders.

• Shares coding-related findings weekly via a SharePoint file with coding partners.

• Leads bi-weekly discussions with coding teams to address second-level review discrepancies.

• Tracks and monitors education opportunities related to coding and CDI while creating tools to enhance accuracy.

• Trains new CDI Specialists on internal procedures.

• Maintains coding-driven statistics for sharing with Revenue Cycle leaders.

⛳️ Requirements

• Willingness to travel up to less than 25% of the time.

• Strong analytical skills (clinical, operational, process, systems).

• Excellent interpersonal skills, both over the phone and in person.

• Experience in clinician coding and reviewing documentation guidelines.

• Proven ability to work independently.

• Adaptability to changes in the rapidly evolving healthcare landscape.

• Familiarity with various electronic health record (EHR) systems.

• Demonstrated ability to communicate effectively with clinicians, nursing staff, and hospital administration.

• Education/Experience: Bachelor’s degree or equivalent combination of education and work-related experience required.

• Minimum of 6 years’ experience in clinical documentation management or coding.

• Proven history of engaging clinicians in documentation improvement.

• Certificates and Licenses (if applicable): CPC or equivalent specialty certification/eligibility preferred.

• Clinical experience strongly preferred (RN, LPN, PA, NPP).

🏝️ Benefits

• Our extensive range of health and welfare benefits enables you to select the options that best suit you and your family.

• Medical.

• Dental.

• Vision.

• Life.

• Disability.

• Healthcare FSA.

• Dependent Care FSA.

• Limited Healthcare FSA.

• FSAs for Transportation and Parking & HSAs.

• Envision Healthcare provides paid time off, 9 observed holidays, and paid family leave. You earn Paid Time Off (PTO) each pay period, and depending on your position, you can accrue a minimum of 20 days and up to 25 days per calendar year.