The Clinical Documentation Specialist will conduct clinically based concurrent and retrospective reviews of inpatient medical records to evaluate the clinical documentation of acute care services. This individual will work closely with physicians and medical staff to facilitate appropriate physician documentation of patient care.

Experience Required:

Has an active RN license with 3+ years of floor experience
3+ years of CDI experience
Knowledge of what conditions impact reimbursements
CCDS or CPC Certification, optional

Job Responsibilities:

Clinically evaluate how the health record translates into coded data, including review of Provider and other clinician documentation, lab results, diagnostic information, and treatment plan.
Provide concurrent and/or retrospective review
Improve documentation of all conditions, treatments, and care plans to ensure the highest quality of care is provided to the patient.
Communicate with Providers via phone call and/or email regarding missing, unclear, or conflicting health record documentation, and clarify the information as warranted.
Gather and analyze information pertinent to documentation findings and outcomes, and use this information to develop action plans for process improvement.
Demonstrate understanding of complications, comorbidities, and the impact of procedures on the billed record, as well as the ability to impact this knowledge to providers and other members of the healthcare team.

Soft Skills:

Possess strong verbal and written communication skills
Demonstrates a high level of accuracy, in a fast-paced environment
Ability to multi-task

Job Types: Full-time, Contract

Pay: $52.00 - $55.00 per hour

Expected hours: 40 per week

Benefits:

Dental insurance
Health insurance
Paid time off
Vision insurance

Schedule:

8 hour shift
Monday to Friday

Experience:

Clinical Documentation Integrity (CDI): 3 years (Required)

License/Certification:

RN (Required)
CCSD (Preferred)
Certified Professional Coder (Preferred)
CRC (Preferred)

Work Location: Remote

Medasource

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Clinical Documentation Integrity Specialist