PHRN/IP CDI

Lunas Solution; Pajo; Presencial; PHP 900.000 - 1.500.000; Jornada completa

Descripción de la vacante

Lunas Solution is seeking a Senior Clinical Documentation Specialist to review inpatient records, identify documentation gaps, and issue compliant physician queries. You will evaluate diagnoses, procedures and SOI/ROM, ensuring accurate ICD-10-CM/PCS coding and DRG assignment.

Collaboration with physicians, coders and CDI teams is essential to drive program quality and standards. The role requires active CDI experience, strong clinical judgment and EPIC/EHR familiarity, with licensure

Formación

• PHRN/USRN license required.
• Minimum 3 years’ clinical experience, preferably in critical care/emergency.
• 4+ years’ clinical experience in non-critical care acute care acceptable.
• IP CDI experience preferred.
• Strong knowledge of ICD-10-CM/PCS, DRGs, CC/MCCs, SOI and ROM.
• Demonstrated experience with physician queries and documentation clarification.
• Epic or major EHR experience preferred.
• CDI certification (CDIP/CCDS/CIC) highly preferred.

Responsabilidades

• Conduct comprehensive reviews of inpatient medical records.
• Identify clinical documentation gaps and opportunities for clarification.
• Develop and issue compliant physician queries.
• Evaluate clinical indicators, diagnoses, procedures, SOI/ROM and CC/MCC opportunities.
• Support accurate ICD-10-CM/PCS and DRG assignment.
• Collaborate with physicians, coders, clinical teams and other healthcare stakeholders.
• Monitor CDI quality, productivity and query performance metrics.
• Provide guidance and mentoring to CDI Specialists.
• Participate in audits, quality improvement and CDI program initiatives.
• Ensure adherence to AHIMA, ACDIS, CMS and organizational CDI standards.

Conocimientos

Clinical judgment

Analytical skills

Physician queries

Documentation clarity

ICD-10 knowledge

DRG knowledge

SOI & ROM

Epic EHR

Educación

PHRN/USRN license

CDI certification (CDIP/CCDS/CIC)

Herramientas

Epic

Descripción del empleo

SENIOR CLINICAL DOCUMENTATION SPECIALIST (CDI)

WHAT YOU'LL DO

• Conduct comprehensive reviews of inpatient medical records
• Identify clinical documentation gaps and opportunities for clarification
• Develop and issue compliant physician queries
• Evaluate clinical indicators, diagnoses, procedures, SOI/ROM and CC/MCC opportunities
• Support accurate ICD-10-CM/PCS and DRG assignment
• Collaborate with physicians, coders, clinical teams and other healthcare stakeholders
• Monitor CDI quality, productivity and query performance metrics
• Provide guidance and mentoring to CDI Specialists
• Participate in audits, quality improvement and CDI program initiatives
• Ensure adherence to AHIMA, ACDIS, CMS and organizational CDI standards

QUALIFICATIONS

• PHRN/USRN license.
• Minimum 3 years’ clinical experience preferably in critical care/emergency setting.
• Will consider candidates with 4+years’ clinical experience in non-critical care acute care settings.
• Prefer candidates with IP CDI experience.
• Strong knowledge of ICD-10-CM/PCS, DRGs, CC/MCCs, SOI and ROM.
• Demonstrated experience with physician queries and documentation clarification.
• Strong clinical judgment and analytical skills.
• Experience with Epic or other major EHR platforms preferred.
• CDI certification such as CDIP, CCDS, or CIC is highly preferred.