Clinical Documentation Improvement Specialist (FT- 1.0 FTE, Day Shift, Remote Possible)
Remote · United States
Job Summary
Clinical Documentation Improvement Specialist responsible for concurrent reviews of inpatient medical records to enhance documentation quality, accuracy, and completeness using ICD-10-CM/PCS. Collaborates with providers for physician queries to support severity of illness, quality metrics, and regulatory compliance, and serves as a resource on coding principles, government regulations, and third-party requirements. Utilizes CDI processes with Epic and 3M 360 Encoder systems to identify opportunities, ensure DRG and diagnosis accuracy, educate clinicians and coders, and maintain HIPAA compliance while driving documentation improvements across the revenue cycle in an acute care setting.
Required Qualifications
- Required Bachelor's degree in Nursing (RN) with current RN licensure; OR Graduate of an accredited or equivalent international medical program or advanced medical program (MD, DO, NP, MBBS or equivalent); OR Ten (10) years of experience in Clinical Documentation Improvement (CDI) in an acute care setting
- At least one of the following CDI or coding credentials/certifications: CCS, CCDS, CDIP, RHIA, RHIT
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