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Clinical Documentation Integrity Specialist - Remote

Med-Metrix -
Remote

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Job Details

Full-time

Qualifications

High school diploma or GED

Full Job Description

Job Purpose
The Clinical Documentation Integrity Specialist focuses on the accuracy, completeness and consistency of inpatient clinical documentation to support coding and reporting of high-quality healthcare data. The Clinical Documentation Integrity Specialist performs concurrent chart reviews to validate that the clinical documentation in the medical record appropriately describes the patient’s severity of illness, complexity of care, and risk of mortality to facilitate appropriate coding. The Clinical Documentation Integrity Specialist utilizes advanced knowledge of disease processes, medications, and has critical thinking to analyze current documentation to identify gaps in clinical documentation.

Duties & Responsibilities

Analyze medical records to identify incomplete, inconsistent, or inaccurate documentation related to diagnoses, treatments, procedures, severity of illness, and risk of mortality
Perform concurrent chart reviews to ensure clinical documentation accurately reflects the patient’s condition, complexity of care, and services rendered to support appropriate coding and reimbursement
Facilitate clarification and modification of clinical documentation through concurrent interaction with physicians and members of the healthcare team to ensure accurate representation of patient severity and DRG assignment
Periodically analyze coding and documentation data to identify trends, variations, and opportunities for documentation improvement, and communicate findings to management
Utilize data analytics, DRG reports, and tracking tools to monitor documentation performance, identify gaps, and support performance improvement initiatives
Collaborate with physicians, nurses, coders, and other healthcare professionals to clarify documentation and obtain additional information necessary for accurate and compliant coding
Provide support to coding teams by ensuring documentation supports code assignment and complies with coding guidelines and regulatory requirements
Communicate effectively with coding staff and healthcare providers to resolve coding-related issues and promote documentation accuracy and consistency
Conduct training and educational sessions for providers and staff on documentation best practices, coding guidelines, compliance requirements, and quality initiatives, as requested by CDI leadership
Demonstrate knowledge of quality measure initiatives, including Value-Based Purchasing, Pay-for-Performance, readmission reduction programs, and related regulatory requirements
Ensure clinical documentation aligns with organizational policies, coding standards, regulatory requirements, and payer guidelines
Conduct routine audits and reviews of clinical documentation to evaluate quality, accuracy, and compliance, and identify opportunities for improvement
Participate in quality improvement initiatives focused on enhancing clinical documentation integrity, coding accuracy, and operational performance
Other duties as assigned
Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
Understand and comply with Information Security and HIPAA policies and procedures at all times
Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties

Qualifications

BSN or PA (Physician's Assistant) or NP (Nurse Practitioner) or Doctorate degree in a medically related field required
High school diploma or equivalent required
Minimum of 3 years of experience in clinical documentation improvement role preferred
Minimum of 5 years nursing experience in adult acute care in med/surg, critical care, emergency, or PACU required
Active RN, MD, DO, NP, or PA license required
Certification minimum requirement – CCDS and/or CDIP
Coding credential (CCS, CPC, CCS-P) is a plus
Current state Registered Nurse license highly preferred
Clinic fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems
Proficient in CDI tools such as encoder or CDI workflow and reporting tool
Proficiency in Microsoft Office Suite
Strong interpersonal skills, ability to communicate well at all levels of the organization
Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses
High level of integrity and dependability with a strong sense of urgency and results oriented
Excellent written and verbal communication skills required

Working Conditions

Must possess a smart-phone or electronic device capable of downloading applications, for multifactor authentication and security purposes
Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear
Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress
Work Environment: The noise level in the work environment is usually minimal

Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.

Work Location: Remote

Apply Now

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