Registered Nurse, Clinical Documentation Integrity Specialist
$78,000–$119,000 year
RemoteColorado, United States
Job Summary
Conduct clinical chart reviews to ensure documentation accuracy by applying established criteria for diagnosing medical conditions, querying providers to clarify missing or ambiguous records in compliance with ACDIS/AHIMA guidelines. Collaborate with healthcare teams to support risk adjustment coding, HCC capture, and adherence to CMS, HHS, and regulatory requirements through provider education on best practices, medical necessity, and content creation. Track and report documentation trends to leadership while maintaining proficiency in EMR systems and MS applications. Perform a comprehensive chart review of 20-30 medical records daily, with full remote availability and occasional travel for in-person training.
Required Qualifications
- Associate's degree
- current active clinical license (RN)
- 3+ years of clinical documentation improvement experience, coding experience, or equivalent
- 1+ year of experience working with advanced practice providers as well as other clinical and non-clinical staff
- Solid clinical background in evidence-based medicine, including chronic disease management and prevention
- Experience in ICD-10 coding and documentation requirements and risk adjustment
- Knowledge of compliant query writing/process
- Ability to perform a comprehensive chart review of 20-30 medical records daily
- Technical experience using EMR systems
- Proficiency in MS applications (Excel, Outlook, Teams, PowerPoint, Word)
- Current active clinical license (RN) without restriction in state of residence
- CCDS-O or CDIP
- CRC
- Fluent in the written and verbal skills necessary to successfully perform the essential functions, duties, and responsibilities of the position
- Ability to lift minimum of 5 lbs to a max of 50 lbs unassisted
- Ability to stand, sit, stoop, walk, stretch, reach, and use full range of body motions
- Manual dexterity as required for specific equipment and ability to use computer keyboard and peripherals
- Fully remote with the ability to travel as needed to present in-person training (travel is 2-4 times per year)
- Must be able to differentiate colors on a test strip
Desired Qualifications
- 5+ years of clinical experience as a Registered Nurse (adult-geriatric or family)
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