Job Details

Clinical Documentation Improvement Specialist
Remote
This is a Remote role.
Compensation: $50 per hour
Contract Duration: 6 months
Start Date: ASAP

ABOUT THE ROLE

Our client is seeking a Clinical Documentation Improvement Specialist for a 6-month remote contract position, available to start immediately. In this role, you will leverage your clinical and coding expertise to conduct concurrent and retrospective reviews of inpatient medical records, identifying opportunities to enhance the quality and accuracy of clinical documentation. You will facilitate and obtain appropriate physician documentation to support accurate severity of illness, risk of mortality, and complexity of care, and lead documentation improvement initiatives. The position involves developing and delivering education to providers and CDI team members, conducting focused reviews in areas such as mortality and PSI, collaborating with coding staff, and serving as a subject matter expert on CDI practices and compliance. You will also be responsible for supporting onboarding and training of new CDI team members, ensuring compliance with Joint Commission requirements, and participating in departmental and organizational projects related to documentation improvement.

WHAT YOU’LL DO

• Conduct concurrent and retrospective reviews of inpatient medical records to evaluate and improve clinical documentation quality.
• Facilitate and obtain appropriate physician documentation to support accurate severity of illness, risk of mortality, and complexity of care.
• Perform focused reviews in areas identified by CDI leadership, such as mortality and PSI reviews, and participate in related projects.
• Communicate review results and recommendations to leadership, CDI specialists, and other staff; recommend corrective actions as needed.
• Develop and deliver ongoing education and training for providers and CDI team members on documentation improvement practices, trends, and areas of opportunity.
• Assist with onboarding and training of new CDI team members and lead new CDI specialist orientation.
• Serve as a subject matter expert and authoritative resource on CDI practices, coding rules, and compliance; conduct risk assessments for compliance deficiencies and documentation improvement opportunities.
• Utilize hospital coding policies, federal and state guidelines, and coding clinic guidelines to assign and review DRGs for accuracy and specificity.
• Initiate physician queries and participate in rounds to resolve ambiguous, missing, or conflicting documentation for accurate coding and compliance, supporting correct CMI, LOS, and optimal resource utilization.
• Collaborate with HIMS coding staff to ensure accuracy and completeness of diagnostic and procedural data for quality outcomes, including working and final DRG assignment, severity of illness, and risk of mortality.
• Lead provider engagement and relationship-building efforts related to CDI and documentation improvement initiatives.
• Lead and participate in departmental and organizational projects focused on documentation improvement.
• Abide by all Joint Commission requirements, including sensitivity to cultural diversity, patient care, patients’ rights, ethical treatment, safety and security, emergency management, teamwork, respect for others, ongoing education, communication, and adherence to safety and quality programs.
• Perform all duties and responsibilities in accordance with hospital programs and sustain compliance with National Patient Safety Goals, licensure, and health screenings.

WHAT YOU BRING

• Bachelor’s degree in a related field (e.g., Nursing, Biology, Health Sciences) preferred.
• Five (5) years of progressively responsible and directly related clinical work experience.
• Two (2) years of experience as a Clinical Documentation Improvement Specialist or equivalent.
• Experience with MS-DRG and APR-DRG focused reviews; quality outcomes (PSI, HAC, etc.) focused CDI review experience preferred.
• Knowledge of AMA, CMS, AAPC medical code sets and coding methodologies (MS DRGs, APR DRGs, HCCs, CPT, E/M codes).
• Expertise in CDI practices, coding, and documentation requirements related to quality outcomes, profiling, and reimbursement; self-motivated to stay current with CMS rules and regulations.
• Ability to conduct concurrent and retrospective reviews of inpatient medical records and analyze problems with an understanding of regulatory, quality outcome, and reimbursement impact.
• Strong interpersonal, verbal, and written communication skills, with demonstrated mastery in collaborating with multidisciplinary teams and delivering formal education/training.
• Experience in public speaking and delivery of formal education, as well as mastery in verbal English communication.
• Proficiency with electronic medical record systems, reporting software, and Microsoft Office applications (Word, Excel, PowerPoint).
• Ability to work independently with minimal supervision, manage multiple tasks, and prioritize work across multiple departments.
• Demonstrated judgment, critical thinking, and independent decision-making skills, with the ability to track activities and communications across multiple groups.
• Highly adaptable and self-aware, with a willingness to seek out and accept change.
• Expertise in developing and maintaining strong, collaborative, and supportive working relationships with CDI peers, physicians, and other clinical professionals.
• Ability to effectively provide and receive feedback, both positive and constructive.
• Knowledge and application of AHIMA and ACDIS ethical standards.