Clinical Documentation Specialist

Omega Healthcare Solutions • Boca Raton, FL

18h • $45 - $55 • Remote

About The Position

This role is responsible for coordinating and maintaining all elements of the Clinical Documentation Improvement Program to meet organizational goals. The specialist ensures timely, accurate, and complete clinical documentation for measuring and reporting physician and hospital outcomes. They will analyze data, create reports, identify trends, and collaborate with coding professionals to resolve discrepancies. The position also involves working effectively with the CDI team, demonstrating continued professional growth, and adhering to company policies, including HIPAA and compliance.

Requirements

• Proven experience with ICD-10-CM/PCS coding, DRG assignment, and query processes.
• Familiarity with CMS Inpatient Prospective Payment System (IPPS), risk adjustment methodologies, and value-based purchasing programs.
• Windows, Excel experience.
• EHR: Epic, Iodine CDI software
• RN, BSN, or foreign medical graduate (FMG) with strong clinical background; OR RHIA/RHIT/CCS credentialed HIM professional with significant inpatient coding experience.
• Certified Clinical Documentation Specialist (CCDS) – ACDIS
• Certified Documentation Improvement Practitioner (CDIP) – AHIMA
• Certified Coding Specialist (CCS) – AHIMA
• Minimum of 3–5 years in clinical practice preferably CCU/ICU, inpatient coding, or CDI role.
• Specialized training in advanced computer skills with proficiency in Microsoft Word, Excel, Power Point, and Outlook e-mail required
• Ability to prioritize and multi-task in a multifaceted environment.
• Demonstrate strong organizational skills and be detail oriented.
• Demonstrate ability to self-motivate, set goals, and meet deadlines.
• Demonstrate mentoring and interpersonal skills.
• Demonstrate excellent presentation, verbal, and written communication skills.
• Ability to develop and maintain relationships with key business partners by building personal credibility and trust.
• Maintains courteous and professional working relationships with employees at all levels of the organization.
• Demonstrate successful leadership skills with the use of critical thinking, problem solving, and deductive reasoning required.

Nice To Haves

• Additional training in Access database management, Medicare Part A and B programs, DRG assignment, and knowledge of MCC/CC preferred
• Preferred: Bachelor’s or Master’s degree in Nursing, HIM, or related healthcare field.
• Bachelor’s degree in healthcare field (e.g., nursing, health information management) OR equivalent combination of education/experience combined required. (One year of education equals one year of experience).
• Minimum of one to three years’ experience in clinical quality, utilization management, case management, nursing, coding, or a related field.
• Three to five years’ experience in a Clinical Documentation Improvement Program with previous experience in clinical quality, utilization management, case management, nursing, coding, or related field (e.g., physician) of which a minimum of three years’ experience is in a management or supervisory role.
• Bachelor’s degree, with a healthcare related credential

Responsibilities

• Coordinates and maintains all elements of the Clinical Documentation Improvement Program in order to meet the goals and objectives of the organization and its stakeholders.
• Meet CDI program objectives, goals, and balance scorecard metrics.
• Ensures timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.
• Ensure effective communications with key stakeholders.
• Analyzes data, creates reports to meet desired outcomes.
• Identifies trends and opportunities for improvement in clinical documentation.
• Meets program quality and productivity guidelines and standards.
• Collaborates with coding professionals to fully support the needs of clinical code assignment, communicates proficiently with coding professionals to resolve identified discrepancies.
• Work effectively with CDI team members to accomplish departmental goals.
• Demonstrates continued advancement in professional growth.
• Perform duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance.

Benefits

• health, dental, and vision coverage
• voluntary insurance options
• a 401(k) plan with employer match
• professional development opportunities
• paid time off
• holiday pay
• bonus programs
• commissions
• other variable incentive plans

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level