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):
• Do you currently hold an active RN license or a CCS or RHIT certification?
• How many years of experience do you have as an acute care Clinical Documentation Integrity (CDI) Specialist?
Work Location: Remote