Clinical Documentation Improvement Specialist
Job Description:
- Conduct concurrent reviews of inpatient medical records to enhance the quality, accuracy, and completeness of documentation.
- Ensure proper code assignment and alignment with the patient’s clinical condition and care provided.
- Collaborate with providers through education and the physician query process to support severity of illness, quality metrics, and regulatory compliance.
- Maintain expertise in coding principles, government regulations, and third-party requirements while serving as a resource for clinicians, coders, and Revenue Cycle teams.
Requirements:
- Bachelor's degree in Nursing (RN) with current Registered Nurse (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: Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT)
- Three (3) years of experience in one of the following areas: Medical/Surgical or Critical Care nursing.
Benefits:
- Health insurance
- 401(k) matching
- Flexible work hours
- Paid time off
- Professional development opportunities
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