Clinical Documentation Specialist Senior (FT, REMOTE)

Centra Health • Lynchburg, VA

2d • Remote

About The Position

The Clinical Documentation Integrity Specialist II (CDI) uses independent clinical judgment to support the integrity, quality, accuracy, and completeness of provider-based clinical documentation in the medical record. The specialist collaborates with healthcare providers, members of the healthcare team, and the Healthcare Information Management (HIM) Coding team to ensure documentation reflects patients’ severity of illness and risk of mortality, and supports appropriate coding and Diagnosis Related Group (DRG) assignment for services rendered. The role reviews medical records and helps ensure clinical information used for profiling and reporting outcomes is complete and accurate.

This position works Monday through Friday on a 40-hour schedule and is remote. The specialist must maintain registered nurse licensure and work toward an advanced nursing degree or Certified Clinical Documentation Integrity Specialist (CCDS) credential. Salary is $36.67–$53.17.

Requirements

• Registered Nurse license in Virginia or a compact state; licensure must be maintained.
• Eligible for CCDS or CDIP.
• Two years of Clinical Documentation Integrity Specialist experience.
• Must have met or exceeded Clinical Documentation Integrity Specialist I skills.
• Complete the CDI competency assessment with 95% accuracy.
• Thorough clinical skills, including current working knowledge of pathology, pharmacology, and surgical procedures.
• Extensive knowledge of disease pathophysiology.
• Excellent written and verbal communication skills.
• Ability to work independently and as a team member in a fast-paced environment.
• Detail-oriented, with relationship-building skills.
• Demonstrated ability to use PCs, Microsoft Office, and general office equipment such as printers, copy machines, and fax machines.
• Ability to work Monday through Friday on a 40-hour work week.

Responsibilities

• Perform timely medical record reviews, determine working DRG assignments, and identify opportunities to clarify documentation so it accurately reflects severity of illness and risk of mortality.
• Follow up promptly with clinical providers to obtain requested documentation clarification.
• Maintain and expand nursing and CDI knowledge, including current research, technology, and treatment modalities.
• Read and understand annual AHIMA coding guidelines, updates, coding clinics, and AHIMA Guidelines for Achieving a Compliant Query Practice.
• Use critical thinking and problem-solving processes and interpret professional association resources and regulatory guidance, including Coding Clinics, AHIMA, ACDIS, and CMS guidelines.
• Identify concurrent and retrospective query opportunities and write compliant, clear queries that clinicians can understand.
• Escalate clinician non-response to queries according to the query escalation policy.
• Collaborate with coding, CDI, clinical staff, medical staff, and other healthcare team members to improve documentation accuracy and comprehensiveness.
• Establish and reconcile DRG processes in compliance with departmental guidelines and CMS regulations.
• Reconcile more than 90% of cases accurately in the CDI database, as determined by quality audit.
• Maintain current CDI production standards and meet established operational, productivity, quality, AHIMA, and ACDIS ethical standards.
• Review increasingly complex severity-of-illness and risk-of-mortality cases and efficiently cover units, specialties, and hospitals.
• Apply knowledge of healthcare workflows and documentation’s impact on quality outcomes, billing, public reporting, research data, quality metrics, provider scorecards, UHDDS accuracy, and case-mix index.
• Follow departmental guidelines for HAC/PSI query opportunities and processes.
• Identify and reduce DRG downgrade and denial risks by ensuring clinical support is valid for DRG integrity, coding, and billing.
• Seek and provide feedback to improve CDI practice and the integrity and quality of medical record documentation.
• Use the CDI business platform, including 3M, PowerChart, and Cerner.
• Maintain Centra Health policies and procedures, including vaccination requirements.
• Perform other duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed