CDI Clinical Consultant

Southern Arizona Legal Aid Inc.; United States; Remote; USD 75,000 - 95,000; Full time

Job summary

A leading organization in legal aid is seeking a Clinical Documentation Improvement Specialist to enhance documentation practices and ensure compliance with healthcare regulations. The role demands a nursing degree and extensive clinical experience. Successful candidates will possess strong interpersonal and analytical skills and will work collaboratively to meet program goals.

Qualifications

• Minimum of 4 years of CDI experience required.
• Five years of acute clinical experience needed.
• Second level review in CDI highly preferred.

Responsibilities

• Maintain knowledge of federal, state, and local documentation guidelines.
• Collaborate to develop, coach, train, and mentor CDI specialists.
• Conduct clinical audits and provide insight into findings.

Skills

Communication techniques

Organizational skills

Interpersonal skills

Critical thinking

Education

Nursing Degree (RN, BS, BSN, or advanced degree)

Master’s degree in healthcare related field

Tools

Microsoft Office

Job description

Assess professional practice gaps, identify needs that can be addressed through education, provide feedback with solutions, assist with implementation and evaluation of strategies.

Identify and resolve conflicts of interest, maintain content integrity

Evaluate data to guide future projects

Function as a content expert as appropriate

Ability to communicate with other stakeholders in other departments for the best outcomes for the program.

Responsibilities:

Maintains knowledge of all federal, state, and local documentation guidelines and communicates changes to all CDI staff; extensive knowledge of I10 and coding guidelines.

Collaborate with the Chief of CDI to develop, coach, train and mentor CDI specialists and clinical staff to improve documentation practices.

Ability to appropriately handle stress and interact with others.

Perform clinical audits of clients and initial reviews of facilities. Provides insight into findings.

Develops and monitors implementation of program departmental goals/objectives

Assist in developing and implementing CDI strategies tailored to client needs and organizational goals.

Serve as a subject matter expert, advising clients and internal stakeholders on best practices in clinical documentation

Ensure documentation meets regulatory requirements, including ICD-10, DRG, and other coding standards.

Use summative evaluation data to guide future projects

Identify gaps in daily operational workflows and provide recommendations for process redesign.

Other duties as assigned.

Qualifications:

Excellent communication techniques in oral and written form and skills and the ability to manage and prioritize multiple projects

Strong interpersonal and organizational skills

Proficient in Microsoft Office applications

Ability to present to management, staff, and business partners

Comfortable in a complex and changing healthcare environment

Broad knowledge of health care regulations including CMS, ICD-10 and DRG optimization along with applicable reporting

Ability to team effectively with people of various disciplines and backgrounds is essential

Apply critical thinking and strong organizational skills

Experienced with risk adjustment and value-based care models

EDUCATION AND EXPERIENCE:

Nursing Degree (RN, BS, BSN, or advanced degree)

Five years of acute clinical experience

Experience in Clinical Documentation Improvement (Acute Care)

Experience with Microsoft Office (Excel, PowerPoint, and Word)

Minimum of 4 years of CDI Experience

Second level review in CDI is high preferred

LICENSURE, CERTIFICATION OR REGISTRATION:

Current valid multi state license as a Registered Nurse

Certified Clinical Documentation Specialist (CCDS) or CCDS-O, CDIP

Master’s degree in healthcare related field strongly preferred (MSN, MHA, MBA)

CPC, CRC, CCS, etc preferred