CDI Clinical Consultant

Mika Meyers PLC; United States; Remote; USD 85,000 - 115,000; Full time

Job summary

A leading healthcare organization seeks a Clinical Documentation Improvement Specialist to assess professional practices and enhance clinical documentation processes. The role requires significant nursing experience and expertise in healthcare regulations, making it essential for the quality of patient care and compliance. Responsibilities include mentoring staff, performing clinical audits, and ensuring documentation meets industry standards. Ideal candidates will have excellent communication and organizational skills and a strong background in healthcare analytics.

Qualifications

• Minimum 4 years of CDI Experience, with acute clinical experience preferred.
• Certified Clinical Documentation Specialist (CCDS) or CCDS-O, CDIP.
• Current valid multi-state license as a Registered Nurse.

Responsibilities

• Ensure documentation meets regulatory requirements, including ICD-10 and DRG.
• Develop and monitor implementation of program departmental goals/objectives.
• Perform clinical audits and provide insight into findings.

Skills

Communication Skills

Interpersonal Skills

Organizational Skills

Critical Thinking

Proficient in Microsoft Office

Education

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

Master’s degree in healthcare related field

Tools

Microsoft Office (Excel, PowerPoint, Word)

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