Clinical Documentation Specialist Senior (FT, REMOTE)

Centra Health • Lynchburg, VA

5d • $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 specialist collaborates with healthcare providers and the Healthcare Information Management (HIM) Coding team to ensure documentation reflects patients’ severity of illness and risk of mortality, supports appropriate coding and Diagnosis Related Group (DRG) assignment for services rendered, and provides complete and accurate clinical information for profiling and outcomes reporting.

The role includes timely medical record review, determining working DRG assignments, identifying documentation opportunities, and following up with clinical providers for clarification. The specialist maintains current CDI and nursing knowledge, applies coding and regulatory guidance, supports compliant query and escalation processes, reconciles cases in the CDI database, and meets departmental production, quality, and ethical standards. The position works across units, specialties, and hospitals and uses the CDI business platform, including 3M, PowerChart, and Cerner.

This is a remote, full-time position with a Monday-through-Friday, 40-hour work week. The specialist must maintain registered nurse licensure and Centra Health policies and procedures, including vaccination requirements. The role is intended for someone working toward an advanced nursing degree or Certified Clinical Documentation Integrity Specialist (CCDS) certification.

Requirements

• Registered Nurse licensure in Virginia or a compact state; licensure must be maintained.
• CCDS or CDIP eligibility.
• At least 2 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 and current working knowledge of pathology, pharmacology, and surgical procedures.
• 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.
• Extensive knowledge of disease pathophysiology.
• Ability to use PCs, Microsoft Office, and general office equipment such as printers, copiers, and fax machines.

Responsibilities

• Review medical records promptly, determine working DRG assignments, and identify opportunities to clarify documentation so it accurately reflects severity of illness and risk of mortality.
• Follow up directly and promptly with clinical providers to obtain requested documentation clarification.
• Expand and maintain nursing and CDI knowledge, including current research, technology, and treatment modalities.
• Read annual AHIMA coding guidelines and updates and understand coding clinics.
• Read AHIMA Guidelines for Achieving a Compliant Query Practice annually.
• Use critical thinking and problem-solving processes.
• Apply professional association resources and regulatory guidance, including Coding Clinics, AHIMA, ACDIS, and CMS guidelines.
• Identify concurrent and retrospective medical-record query opportunities and write queries that clinicians can readily understand.
• Escalate clinician non-response to queries according to the query escalation policy.
• Collaborate with coding, the CDI team, clinical staff, and other healthcare team members to improve medical-record documentation and accurate quality-outcome reporting.
• Establish and reconcile DRG processes in compliance with departmental guidelines and CMS regulations.
• Accurately reconcile more than 90% of cases in the CDI database, as determined by quality audit.
• Maintain current CDI specialist production standards and meet established operational, productivity, quality, and AHIMA/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 support accurate and comprehensive documentation, including HAC/PSI query opportunities and departmental processes.
• Help reduce DRG downgrades and denial risks by ensuring clinical support is valid for DRG integrity, coding, and billing.
• Provide and seek feedback to improve CDI practice and the integrity and quality of medical-record documentation.
• Use the CDI business platform, including 3M, PowerChart, and Cerner.
• Perform other duties as assigned.
• Work Monday through Friday for a 40-hour work week.
• Maintain Centra Health policies and procedures, including vaccination requirements.
• Maintain registered nurse licensure and work toward an advanced nursing degree or CCDS certification.

What This Job Offers

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