Clinical Documentation Specialist Senior (FT, REMOTE)

Centra Medical Group • Lynchburg, VA

3d • $37 - $53 • 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 role collaborates with healthcare providers, members of the healthcare team, and the Healthcare Information Management (HIM) Coding team to ensure documentation reflects each patient's severity of illness and risk of mortality and supports appropriate coding and Diagnosis Related Group (DRG) assignment for the services provided. The specialist reviews medical records and helps ensure clinical information used for profiling and outcome reporting is complete and accurate.

The position conducts timely concurrent and retrospective reviews, identifies documentation clarification opportunities, and follows up with clinicians on queries. It applies clinical expertise, coding guidance, regulatory requirements, and departmental processes to support accurate DRG assignment, compliant queries, quality outcomes, and reduced downgrade or denial risk. The specialist maintains current clinical and CDI knowledge and meets established quality, productivity, and ethical standards.

Requirements

• Registered Nurse licensure in Virginia or a compact state.
• CCDS or CDIP eligibility.
• Two years of Clinical Documentation Integrity Specialist experience.
• Has 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 player 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.

Nice To Haves

• Working toward an advanced nursing degree or Certified Clinical Documentation Integrity Specialist (CCDS).

Responsibilities

• Perform timely medical record reviews, determine working Diagnosis Related Group (DRG) assignments, and identify documentation opportunities that accurately reflect severity of illness (SOI) and risk of mortality (ROM).
• Follow up promptly with clinical providers to obtain requested documentation clarification and escalate clinician non-response according to policy.
• Identify concurrent and retrospective query opportunities and write compliant queries that clinicians can readily understand.
• Maintain and expand nursing and Clinical Documentation Integrity knowledge, including current research, technology, treatment modalities, coding guidance, and regulatory guidelines.
• Read annual AHIMA coding guidelines and updates, understand coding clinics, and review AHIMA Guidelines for Achieving a Compliant Query Practice annually.
• Use critical thinking and problem-solving processes and appropriately apply resources and guidelines from Coding Clinics, AHIMA, ACDIS, and CMS.
• Collaborate with coding, the CDI team, 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 cases in the CDI database accurately more than 90% of the time, as measured by quality audit.
• Meet current CDI production standards, operational and productivity standards, quality standards, and AHIMA and ACDIS ethical standards.
• Review increasingly complex SOI and ROM cases and efficiently cover all units, specialties, and hospitals.
• Apply knowledge of healthcare workflows and documentation's impact on billing, public reporting, research data, quality metrics, provider scorecards, UHDDS accuracy, and case mix index.
• Identify and reduce DRG downgrade and denial risks by ensuring clinical support is valid for DRG integrity, coding, and billing.
• Use the CDI business platform, including 3M, PowerChart, and Cerner.
• Seek and provide feedback to improve CDI practice and the integrity and quality of medical record documentation.
• Maintain Centra Health policies and procedures, including vaccination requirements, and maintain registered nurse licensure.
• Work Monday through Friday for a 40-hour work week.
• Perform other duties as assigned.

What This Job Offers

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