Clinical Documentation Improvement Specialist
Omega Healthcare Management Services
Remote · Full Time
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- Experience
- 5–8 yrs
- Salary
- —
- Openings
- 5
- Posted
- 3 weeks ago
- Work mode
- Work from home
- Education
- Active RN license
- Eligibility
- Registered Nurses with active licenses in IA, WI, IL, SD, or a Compact US Nursing License, and the specified clinical and CDI experience.
- Resume
- Required to apply
Job description
About the Role
Omega Healthcare Management Services is seeking experienced Clinical Documentation Improvement Specialists to join our remote team. This role is crucial for ensuring the accuracy and completeness of patient medical records. We are looking for dedicated professionals with a strong background in clinical nursing and a passion for improving healthcare documentation processes.
Responsibilities
- Conduct concurrent chart reviews to ensure clinical documentation accurately reflects the patient's condition and care provided.
- Identify and query physicians and other healthcare providers to obtain necessary clarifications and additional documentation.
- Collaborate with clinical staff to improve the quality of documentation.
- Analyze medical records for completeness, accuracy, and compliance with regulatory standards.
- Utilize the Epic electronic health record system for documentation review and query management.
- Maintain up-to-date knowledge of clinical documentation guidelines and best practices.
Requirements
- A minimum of 5 years of direct bedside clinical nursing experience in an Adult Intensive Care Unit (ICU), Critical Care Unit (CCU), or Medical-Surgical Unit.
- Active Registered Nurse (RN) license in Iowa (IA), Wisconsin (WI), Illinois (IL), South Dakota (SD), or a Compact US Nursing License.
- At least 2 years of experience specifically in Clinical Documentation Integrity (CDI) involving concurrent chart review.
- A minimum of 2 years of hands-on experience with the Epic electronic health record system.
- Demonstrated experience in writing provider queries to improve documentation.
- Your resume must clearly demonstrate all the required experience outlined.
Preferred Experience
- Experience utilizing Nuance CDE (Computer-Assisted Coding/Documentation) is considered a significant advantage.
Additional Information
This is a full-time, remote position based in the United States. We are looking for candidates who can immediately contribute to our team.