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Inpatient Clinical Documentation Integrity (CDI) Specialist
Remote · Tempo total
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- Experiência
- 3+ anos
- Salário
- —
- Vagas
- 1
- Publicado
- há 5 dias
- Modo de trabalho
- Trabalhe em casa
- Retomar
- Obrigatório candidatar-se
Descrição da vaga
Role Overview
We are seeking a knowledgeable Inpatient Clinical Documentation Integrity Specialist to enhance our expanding team. This vital position involves collaborating directly with hospital executives, physicians, and coding personnel to guarantee precise clinical documentation, optimize diagnosis-related groups (DRG) outcomes, and elevate overall care quality.
Primary Responsibilities
- Conduct both concurrent and retrospective assessments of inpatient records to verify documentation accuracy.
- Initiate compliant physician queries to clarify clinical diagnoses, procedures, severity of illness (SOI), risk of mortality (ROM), and key quality indicators.
- Collaborate with coding and Health Information Management (HIM) teams to address and resolve inconsistencies in DRG assignments and documentation lapses.
- Provide clinical validation support, ensuring conformity with ICD-10-CM/PCS coding standards and regulatory mandates.
- Offer education and constructive feedback to physicians, leadership, and clinical staff to improve documentation practices.
- Analyze documentation trends and generate impact reports on CDI effectiveness across healthcare facilities.
Qualifications
- Minimum of three years’ experience in inpatient CDI within a hospital environment.
- Comprehensive understanding of ICD-10-CM/PCS coding, Medicare Severity Diagnosis Related Groups (MS-DRG), and All Patient Refined Diagnosis Related Groups (APR-DRG) systems.
- Familiarity with American Health Information Management Association (AHIMA) physician query protocols and regulatory compliance standards.
- Possession of at least one certification such as CCDS, CDIP, CCS, RHIT, or RHIA is mandatory.
- A registered nurse (RN) or clinical background is highly preferred.
- Exceptional communication skills to effectively engage with physicians and organizational leadership.
Compensation and Benefits
- Flexible employment structure allowing remote work or travel based on assignment requirements.
- Engagement with premier hospitals and healthcare systems.
Additional Information
This position offers a chance to join a consulting group recognized for its excellence in Clinical Documentation Integrity and revenue integrity. Your role will significantly impact patient care quality and institutional performance across medical facilities.