Clinical Documentation Integrity Specialist

Anne Arundel Health System • Annapolis, MD

293d • $83,200 - $124,800 • Remote

About The Position

The Clinical Documentation Integrity Specialist at Luminis Health Clinical Enterprise is responsible for reviewing and analyzing health records to identify relevant diagnoses and procedures for distinct patient encounters. This role involves collaboration with physicians, healthcare professionals, and coding staff to ensure that clinical information in medical records is accurate and complete, facilitating appropriate reimbursement for patient care services. The specialist must stay informed about changes in Federal and State regulations and perform coding when physician documentation is vague or missing.

Requirements

• At least one of the following: Physician, Registered Nurse, Nurse Practitioner, Physician Assistant, or a Professional Coder.
• Minimum of three to five years of healthcare experience.
• Strong medical surgical background preferred.
• Experience with utilization management, coding/DRG, billing, auditing, and various healthcare payers preferred.
• Clinician preferred and/or CDIP/CCDS credential.
• Experience as a CDI Specialist is highly preferred.

Nice To Haves

• Knowledge of basic computer programs and Microsoft Office Suite.
• Inpatient coding skills.
• High level of interpersonal and communication skills necessary to establish rapport with physicians and other healthcare providers.
• Chart review experience.
• Electronic Medical Record and CDI Software experience preferred.
• Regulatory background and DRG reimbursement knowledge preferred.

Responsibilities

• Reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters.
• Translates diagnostic phrases utilized by healthcare providers into coded form.
• Interacts with healthcare providers to ensure correct translation of terms.
• Assigns the appropriate DRG after concurrent review of the medical record.
• Works as part of a coding team.
• Maintains awareness of changes in Federal and State regulations for prospective payment.
• Keeps informed of changes in treatment modes and new procedures.
• Performs coding when physician documentation is vague or missing.

Benefits

• Medical, Dental, and Vision Insurance
• Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year)
• Paid Time Off
• Tuition Assistance Benefits
• Employee Referral Bonus Program
• Performance Based - Leadership Variable Pay Program
• Paid Holidays, Disability, and Life/AD&D for full-time employees
• Wellness Programs
• Employee Assistance Programs and more

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Bachelor's degree