CDI Clinical Consultant

CSI; United States; Remote; USD 70,000 - 100,000; Full time

Job summary

A leading company in healthcare seeks a Clinical Documentation Improvement Specialist to assess practice gaps and provide educational solutions. The role involves collaborating with clinical staff, ensuring documentation meets regulatory standards, and advising on best practices. Ideal candidates will possess significant experience in clinical settings and relevant certifications, ensuring they can effectively enhance documentation processes across the organization.

Qualifications

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

Responsibilities

• Collaborate with the Chief of CDI to improve documentation practices.
• Perform clinical audits of clients to provide insights into findings.
• Develop and monitor implementation of departmental goals.

Skills

Communication

Interpersonal Skills

Organizational Skills

Critical Thinking

Education

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

Master’s degree in healthcare related field

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

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