Clinical Documentation reputed company Specialist/ Part time- Remote, reputed

vacancy global pro; India; Remote; INR 5,826,000 - 9,647,000; Full time

Benefits offered by this job

Medical, Rx, Dental & Insurance

401(k) Retirement Plan

Tuition Reimbursement

Employee Referral Program

Parental Leave

Health Savings Account

Short-Term & Long-Term Disability

Learning Opportunities

Corporate Sponsored Events

Job summary

reputed company seeks a CDI Specialist to review inpatient records and ensure documentation supports diagnosis-related grouping and regulatory standards. You will work with Coders, Educators, Auditors, Case Managers, and Providers to ensure accuracy and appropriate severity of illness.

Strong clinical knowledge is essential for success. Daily chart reviews, DRG assignments, and CDI data entry are central to the role, with physician queries when needed and collaboration across departments to

Qualifications

• Bachelor's degree required.
• One of RN, MD, or MD Equivalent (MBBS).
• 4 years' inpatient patient care experience; critical care/ED or strong med-surg preferred.
• 2+ years CDI experience.
• Familiarity with encoder and DRG assignment.
• Knowledge of official coding guidelines and coding clinics.

Responsibilities

• Perform comprehensive chart reviews to identify documentation gaps.
• Collaborate with Coders, Educators, Auditors, Case Managers, and Providers to ensure accurate documentation reflecting severity and risk.
• Review daily inpatient records to ensure complete documentation at discharge.
• Manage initial DRG assignment and CDI data entry for case reviews.
• Update DRG as supported by documentation or query responses.
• Communicate workload to CDI Coordinator for assignment balancing.
• Initiate and follow up on compliant physician queries when documentation is unclear.

Skills

RN/MD background

Critical thinking

Interpersonal skills

Clinical knowledge

Education

Bachelor's degree

Tools

Encoder systems

DRG assignment

EHR systems

CDI software systems

Job description

34078

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

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 RecruitingAccommodation@repute