Clinical Documentation reputed company Specialist/ Part time

remotepromsp; India; On-site; INR 5,810,000 - 9,619,000; Full time

Job summary

reputed company is seeking a CDI Specialist to perform comprehensive secondary clinical chart reviews and ensure documentation aligns with severity of illness and mortality risk. The role collaborate with Coders, Educators, Auditors, Case Managers and Providers to maintain compliant documentation.

The position involves daily inpatient record reviews, DRG assessment, and CDI software data entry, with physician queries when needed and timely follow-up to obtain responses.

Qualifications

• Bachelor's degree required in nursing, medicine, or related field.
• 4 years' experience delivering patient care in inpatient settings.
• 2+ years prior CDI experience.
• Familiarity with encoder and DRG assignment.
• Working knowledge of official coding guidelines and coding clinics.

Responsibilities

• Review inpatient charts to ensure documentation supports severity of illness and mortality risk.
• Collaborate with Coders, Educators, Auditors, Case Managers and Providers to ensure accurate, compliant documentation.
• Submit physician queries for clarification when documentation is unclear or missing.
• Update DRG assignments as supported by documentation or query responses.
• Communicate workload to the CDI Coordinator to adjust review assignments.

Skills

CDI experience

Critical thinking

Interpersonal skills

Education

Bachelor's degree

RN

MD

MD Equivalent (MBBS)

Tools

Encoder

DRG assignment

EHR software

CDI software

Job description

Job Family: CDI Specialist Travel Required: None Clearance Required: None

What You Will Do:

The CDI Specialist is responsible for comprehensive secondary clinical chart reviews to identify potential missed opportunities for documentation clarification. Collaborates closely with Coders, Coding Educators, Coding reputed company Auditors, Case managers, reputed company Department and Providers to assure documentation is clinically appropriate, accurately reflects the severity of illness and risk of mortality for the patient and is reputed company of reputed company CMS or other regulatory standards. Conducts daily, reputed company review of inpatient records on assigned unit(s) to ensure complete and accurate physician and or clinician documentation is present at the time of discharge for accurate, reputed company, and compliant coding. Reviews daily admissions to assigned unit, reputed company initial reputed company assignment for a working DRG and complete CDI software data entry for initial and follows up case reviews (or worksheet to include reputed company and DRG assignment) and submit to Program Assistant. Updates working DRG as documentation supports, or physician query answer supports a change in the DRG assignment. Communicates to the CDI Coordinator reputed company volume of daily review assignments is too high or low so that CDI Coordinator can assist in adjusting review assignments amongst reputed company. Initiates compliant physician queries reputed company documentation is confusing, ambiguous, or missing and follows up with MD to reputed company immediate response to query (utilizing the following reputed company reputed company briefs as a guide: Managing an Effective Query Process, reputed company 2008 and Guidance for Clinical Documentation Improvement Programs, May 2010).

What You Will Need:

• Bachelor's degree
• One of the following: RN, MD, or MD Equivalent (MBBS)
• 4 years' experience providing reputed company patient care to acute and chronically ill patients in inpatient settings, critical care, ED or strong med-surg experience preferred.
• 2 + years prior CDI experience
• Familiarity with encoder and DRG assignment
• Maintain reputed company working knowledge of official coding guidelines and coding clinics

What Would Be reputed company to Have:

• CCDS, CDIP preferred
• ED/Critical care or case management; or inpatient acute care (referral hospital); strong critical thinking skills; strong interpersonal skills; strong clinical knowledge reputed company.
• Coding, Case Management and/or Utilization Review experience preferred.
• Strong clinical understanding of disease process
• Demonstrate critical thinking, analytical skills, and ability to reputed company problems.
• Strong knowledge of medical terminology, anatomy, physiology, microbiology, and disease processes
• Ability to converse with physicians in sometimes difficult scenarios
• Strong typing and computer skills; proficiency with EHR systems, CDI software systems and encoders

Compensation

#Indeedsponsered #LI-DNI The annual salary reputed company for this position is $61,000.00-$101,000.00. Compensation reputed company depend on a wide reputed company of factors, including but not limited to reputed company sets, experience and training, reputed company clearances, licensure and certifications, and other business and organizational needs. reputed company Offer: reputed company offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace.

Benefits include:

• Medical, Rx, Dental & reputed company Insurance
• Personal and Family reputed company Time & Company reputed company Holidays
• Position may be eligible for a discretionary variable incentive bonus
• Parental Leave
• 401(k) Retirement Plan
• Basic Life & Supplemental Life
• Health Savings Account, Dental/reputed company & Dependent Care Flexible Spending Accounts
• Short-Term & Long-Term Disability
• Tuition Reimbursement, Personal Development & Learning Opportunities
• Skills Development & Certifications
• Employee Referral Program
• Corporate Sponsored Events & Community reputed company
• Emergency Back-Up Childcare Program

About reputed company

reputed company is an Equal Opportunity EmployerProtected Veterans, Individuals with Disabilities or any other reputed company protected by law, ordinance, or regulation. reputed company will consider for employment reputed company applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco. If you have visited our website for information about employment opportunities, or to apply for a position, and you require an accommodation, please contact reputed company reputed company at 1-hidden_mobile or reputed company email at hidden_email.