About This Position
Job Title: RN Clinical Documentation Specialist
Contract Length: 6 month-1 year
Location: Fully Remote
Hours: Standard PST/CST hours
Start Date: July 20th
Primary Responsibilities
Completes initial medical records reviews within 24-48 hours of admission for a specified patient population to evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality and severity of illness
Conducts follow-up reviews every 2-3 days to support working DRG assignment
Formulates compliant provider queries regarding missing, unclear or conflicting documentation, as necessary
Follows up daily on open queries with providers to ensure timely responses
Reviews final coding DRG assignment follows DRG reconciliation process
Keep abreast of Official Coding and Reporting Guidelines, AHA Coding Clinics, CMS and other agency directives and maintains up to date knowledge of coding and CDI current trends
Strong oral communication skills and the ability to deliver presentations to large groups
Actively seeks to promote and helps to maintain a professional, team-oriented, service-conscious environment, which contributes to the goals of the team and reflects the values of the enterprise
Proactively develops a collaborative relationship with the HIM Coding Professionals
Collaborates with leadership when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process
Ability to troubleshoot computer issues in a timely fashion while working remotely
Required Qualifications
Ability to analyze opportunities for documentation improvement and integrity of the medical record
Ability to formulate compliant queries
Knowledge of disease management, anatomy and physiology, medical terminology, pharmacology and current coding classification systems
Understand and communicate documentation strategies
Capacity to work independently in a virtual office setting or at facility setting, if required to travel for assignment
Experience with various encoder and EMR systems (Optum eCAC, Solventum, EPIC, Cerner, Meditech)
Ability to apply coding conventions, official guidelines, and AHA Coding Clinic advice
Analytical/critical thinking and problem
Required Qualifications
Current RN license and/or CCS/RHIT certification
5+ years’ acute care hospital clinical CDI experience or 5+ years’ experience inpatient coding auditor
Preferred Qualifications/Licensures:
CCDS, CDIP or CCS certification
CAC experience (Computer Assistant Coding)
Bachelor’s degree in Nursing, or HIM
Pay: $45.00 - $50.00 per hour
Benefits:
Dental insurance
Health insurance
Vision insurance
Application Question(s):
How many years of experience do you have as an acute care Clinical Documentation Integrity (CDI) Specialist?
Do you currently hold an active RN license AND a CCS or RHIT certification?
Work Location: Remote
Contract Length: 6 month-1 year
Location: Fully Remote
Hours: Standard PST/CST hours
Start Date: July 20th
Primary Responsibilities
Completes initial medical records reviews within 24-48 hours of admission for a specified patient population to evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality and severity of illness
Conducts follow-up reviews every 2-3 days to support working DRG assignment
Formulates compliant provider queries regarding missing, unclear or conflicting documentation, as necessary
Follows up daily on open queries with providers to ensure timely responses
Reviews final coding DRG assignment follows DRG reconciliation process
Keep abreast of Official Coding and Reporting Guidelines, AHA Coding Clinics, CMS and other agency directives and maintains up to date knowledge of coding and CDI current trends
Strong oral communication skills and the ability to deliver presentations to large groups
Actively seeks to promote and helps to maintain a professional, team-oriented, service-conscious environment, which contributes to the goals of the team and reflects the values of the enterprise
Proactively develops a collaborative relationship with the HIM Coding Professionals
Collaborates with leadership when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process
Ability to troubleshoot computer issues in a timely fashion while working remotely
Required Qualifications
Ability to analyze opportunities for documentation improvement and integrity of the medical record
Ability to formulate compliant queries
Knowledge of disease management, anatomy and physiology, medical terminology, pharmacology and current coding classification systems
Understand and communicate documentation strategies
Capacity to work independently in a virtual office setting or at facility setting, if required to travel for assignment
Experience with various encoder and EMR systems (Optum eCAC, Solventum, EPIC, Cerner, Meditech)
Ability to apply coding conventions, official guidelines, and AHA Coding Clinic advice
Analytical/critical thinking and problem
Required Qualifications
Current RN license and/or CCS/RHIT certification
5+ years’ acute care hospital clinical CDI experience or 5+ years’ experience inpatient coding auditor
Preferred Qualifications/Licensures:
CCDS, CDIP or CCS certification
CAC experience (Computer Assistant Coding)
Bachelor’s degree in Nursing, or HIM
Pay: $45.00 - $50.00 per hour
Benefits:
Dental insurance
Health insurance
Vision insurance
Application Question(s):
How many years of experience do you have as an acute care Clinical Documentation Integrity (CDI) Specialist?
Do you currently hold an active RN license AND a CCS or RHIT certification?
Work Location: Remote
