CDI Clinical Consultant

Barmont; United States; Remote; USD 75,000 - 110,000; Full time

Job summary

A prominent healthcare organization is seeking a Clinical Documentation Improvement Specialist to enhance documentation practices across departments. The role involves training clinical staff, ensuring compliance with healthcare regulations, and utilizing data to guide future projects. Candidates should possess a nursing degree, extensive clinical experience, and effective communication skills in a dynamic healthcare environment.

Qualifications

• Minimum of five years of acute clinical experience.
• At least four years of CDI experience.
• Valid multi-state license as a Registered Nurse.

Responsibilities

• Ensure documentation compliance with regulatory requirements.
• Collaborate with the Chief of CDI to train and mentor staff.
• Perform clinical audits and initial reviews of facilities.

Skills

Communication

Interpersonal skills

Organizational skills

Critical thinking

Education

Nursing degree (RN, BS, BSN, or higher)

Master’s degree in a healthcare-related field (MSN, MHA, MBA)

Tools

Microsoft Office

Job description

Assess professional practice gaps, identify educational needs, provide feedback with solutions, and 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.

Communicate effectively with stakeholders across departments to ensure optimal program outcomes.

Responsibilities:

Maintain knowledge of all federal, state, and local documentation guidelines and communicate changes to all CDI staff; possess extensive knowledge of ICD-10 and coding guidelines.

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

Handle stress appropriately and interact professionally with others.

Perform clinical audits of clients and initial reviews of facilities, providing insights into findings.

Develop and monitor departmental goals and objectives.

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

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

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

Use summative evaluation data to guide future projects.

Identify operational workflow gaps and recommend process redesigns.

Other duties as assigned.

Qualifications:

Excellent communication skills, both oral and written, with the ability to manage multiple projects effectively.

Strong interpersonal and organizational skills.

Proficiency in Microsoft Office applications.

Ability to present to management, staff, and business partners.

Comfortable working in a complex and evolving healthcare environment.

Broad knowledge of healthcare regulations, including CMS, ICD-10, and DRG optimization, along with applicable reporting standards.

Effective team collaboration with diverse disciplines and backgrounds is essential.

Apply critical thinking and organizational skills.

Experience with risk adjustment and value-based care models.

Education and Experience:

Nursing degree (RN, BS, BSN, or higher).

Minimum of five years of acute clinical experience.

Experience in Clinical Documentation Improvement (Acute Care).

Proficiency in Microsoft Office (Excel, PowerPoint, Word).

At least four years of CDI experience.

Second-level review experience in CDI is highly preferred.

Licensure, Certification, or Registration:

Valid multi-state license as a Registered Nurse.

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

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

Additional certifications such as CPC, CRC, CCS are preferred.