Clinical Documentation Integrity Specialist
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Job Description
Remote Clinical Documentation Integrity Specialist improving inpatient documentation for accurate coding and reimbursement. Reviewing charts, clarifying records with providers, and supporting healthcare data quality at Med-Metrix.
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
- 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 and support performance improvement initiatives
- Collaborate with physicians, nurses, coders, and other healthcare professionals to clarify documentation and obtain additional information
- Support coding teams by ensuring documentation supports code assignment and complies with coding guidelines and regulatory requirements
- Communicate with coding staff and healthcare providers to resolve coding-related issues
- Conduct training and educational sessions for providers and staff on documentation best practices, coding guidelines, compliance requirements, and quality initiatives
- 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
- Participate in quality improvement initiatives focused on clinical documentation integrity, coding accuracy, and operational performance
- Use, protect, and disclose patients’ protected health information only in accordance with HIPAA standards
- Comply with Information Security and HIPAA policies and procedures
- Limit viewing of PHI to the absolute minimum necessary to perform assigned duties
- Perform other duties as assigned
Requirements:
- 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 required
- 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
- Must possess a smart-phone or electronic device capable of downloading applications
- Must be able to follow directions, collaborate with others, and handle stress
Benefits:
- Remote work arrangement
- Smartphone or electronic device capable of downloading applications for multifactor authentication and security purposes
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