About The Position

The CDI Specialist collaborates with physicians, nursing staff, other patient caregivers, and medical records coding staff to improve the quality, specificity, accuracy, and completeness of care documentation and coding. The role reviews medical records for diagnosis clarification and validity as they relate to DRG assignment, severity of illness, risk of mortality, case mix data, and timely, accurate documentation of clinical information used to measure and report physician and facility outcomes. These objectives are accomplished through chart review and query placement, following AHIMA guidelines and company policies and procedures. This is a remote, full-time position with a predictable schedule. The specialist conducts clinical documentation reviews in accordance with project productivity and quality standards, coding and documentation guidelines, and client requirements. The role requires accurate and timely record review, analytical skills, attention to detail, and the ability to work across multiple projects with minimal supervision. The position requires CCDS or CDIP certification, or willingness to obtain CCDS certification within six months of employment, a current RN license, and three years of CDI experience. Two or more years of clinical experience in an acute care setting is preferred. The role involves extended computer work, prolonged sitting at times, and occasional lifting and moving of materials weighing up to 20 pounds.

Requirements

  • CCDS or CDIP certification, or willingness to obtain CCDS certification within six months of employment.
  • Current RN license.
  • Three years of CDI experience.
  • Experience with telecommuting, EMRs, and other electronic tools.
  • Strong analytical skills.
  • Strong Microsoft Office skills.
  • Ability to work well with numbers.
  • Strong team-player skills.
  • Ability to work with multiple and diverse clients and projects.
  • Ability to work with minimal supervision.
  • Ability to maintain and access multiple files.
  • Ability to complete work with high accuracy and attention to detail.

Nice To Haves

  • Two or more years of clinical experience in an acute care setting.

Responsibilities

  • Conduct clinical documentation tasks while meeting project productivity and quality standards.
  • Follow coding and clinical documentation improvement guidelines endorsed by AHIMA and ACDIS.
  • Review clinical documentation and issue queries when appropriate.
  • Review medical records for completeness and accuracy in documenting severity of illness and risk of mortality.
  • Complete record reviews accurately and in a timely manner.
  • Apply knowledge of DRG payer issues, documentation opportunities, and clinical documentation requirements.
  • Analyze findings and identify potential root causes of errors.

Benefits

  • Medical, dental, and vision coverage.
  • 401(k) with match.
  • Long-term disability insurance.
  • Life insurance.
  • Holidays and ample paid time off.
  • Allowance for CME and/or license renewal.
  • Opportunities for career growth within the organization.
  • Remote, predictable, full-time schedule.
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