Clinical Documentation & Integrity Specialist - Remote | WFH

Job Summary

This position plays a crucial role in conducting concurrent reviews of inpatient medical records to enhance the quality of physician documentation. The CDI Specialist engages in ongoing interactions with physicians and healthcare teams, both face-to-face and electronically, to facilitate timely improvements in clinical documentation. The primary objective is to ensure comprehensive... and accurate medical records that support precise coding.

Job Description

We are currently seeking a Remote Clinical Documentation Improvement (CDI) Specialist residing in one of the following states:

Texas

Louisiana

Oklahoma

Nebraska

Florida

Georgia

Tennessee

South Carolina

Desired Skills

Preferably a Registered Nurse (RN) with experience in Clinical Documentation.

Bachelor of Science in Nursing (BSN) required.

Critical care nursing experience highly valued.

Minimum Qualifications

Education: Bachelor of Nursing required.

Licenses/Certifications: Current state nursing license (Texas or temporary/compact license).

Experience: Minimum of five (5) years in inpatient acute care, preferably in ICU settings.

Skills: Strong observational, analytical, problem-solving, verbal, and written communication skills. Proficiency in computer usage, including database and spreadsheet analysis, presentation programs, word processing, and internet research.

Key Responsibilities

Collaborate effectively with physicians, case managers, coders, and other healthcare team members to ensure comprehensive documentation.

Utilize designated clinical documentation systems to identify opportunities for improving physician and hospital outcomes.

Provide education to internal stakeholders on compliance, coding, and clinical documentation issues.

Evaluate documentation daily to ensure alignment with hospital standards and regulatory requirements.

Contribute to a positive work environment and support organizational initiatives.

Develop strategies for physician education to enhance clinical documentation accuracy.

Stay updated on CMS rules and regulations, integrating changes into daily practice.

Participate in service line meetings, reviewing outcomes and educating physicians on improvement opportunities.

Adhere to HIPAA and Code of Conduct policies.

Assist with special projects as required.

Demonstrate competency in customer service, job skills, resource management, teamwork, and innovation.

Ensure patient, staff, and visitor safety by following organizational policies and procedures.

Professional Development

Support department goals through continuing education and skills development.

Act as a mentor and resource to less experienced staff members.

Commitment To Community

Other Duties:

Perform other duties as assigned.

Employment Type: Full-Time

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