CDI Consultant

e4health; United States; Remote; USD 75,000 - 95,000; Full time

Benefits offered by this job

401(k) matching

Medical insurance

Dental insurance

Vision insurance

PTO

Job summary

e4health seeks a CDI Consultant to provide timely reviews of patient records, ensuring accurate documentation that reflects illness severity and complexity. You will educate providers and collaborate with coders to support complete, compliant chart notes while following HIPAA and regulatory guidelines.

The role requires 3+ years of clinical documentation experience and an active RN license, with travel up to 15% and a full benefits package.

Qualifications

• 3+ years of clinical documentation experience.
• Current RN license.
• Strong analytical skills to clinically evaluate the medical record.
• Proficient with Microsoft Office (Excel, Word, Outlook).
• Effective communication with e4health management and clients.

Responsibilities

• Perform concurrent and/or retrospective review of health records to identify documentation opportunities.
• Use clinical knowledge and coding guidance to support complete, accurate, and compliant documentation of the patient’s story.
• Initiate and complete queries to reflect accurate data for inpatient or outpatient visits.
• Adhere to client procedures and guidelines (ACDIS, AAPC, AHIMA).
• Maintain confidentiality of all patient information per HIPAA.
• Collaborate with providers, coders, and management to meet assignment needs.

Skills

Clinical documentation

Analytical skills

MS Office

Communication

Education

RN license

BSN (preferred)

Tools

Microsoft Excel

Microsoft Word

Microsoft Outlook

Job description

At e4health, we Empower Better Health. The e4health Team is on a relentless mission to care for those teams who care for others. We bring our passion, ingenuity, and expertise to every engagement. In joining our Team, we want your help to provide our customers with powerful solutions in the pursuit of quality, integrity, clinical and financial value across healthcare.

Our People make the difference. Serving more than 400 hospitals and health systems nationwide for nearly two decades, e4health provides solutions to tackle the toughest problems in healthcare with unmatched technology, mid-revenue cycle, and operational expertise. e4health solutions streamline clinical, financial, and health information data and workflows, optimize coding, quality, and clinical documentation integrity processes, and address health IT operational challenges to deliver material results for healthcare organizations across the country. Learn more about us at www.e4.health.

The Clinical Documentation Integrity (CDI) Consultant will provide timely reviews of patient medical records to ensure accurate and complete documentation to reflect the patient’s severity and complexity of illness. The CDI Consultant is expected to work with providers and coders to ensure that documentation on the chart reflects the complexity of the patient. The ability to educate and interact with providers is essential.

• Perform concurrent and/or potential retrospective review of the health record to identify opportunities for documentation clarification and improvement.
• Using clinical expertise, critical thinking, and knowledge of coding and regulatory requirements, the CDS collaborates with providers and other healthcare professionals to support complete, accurate, compliant, and clinically supported documentation of the patient’s story.
• Must follow all customer established procedures
• Review medical records as assigned for complete and accurate documentation of all relevant diagnoses and procedures
• Initiate and complete queries as necessary to reflect accurate data regarding the patient’s inpatient or outpatient visit
• Adhere to guidelines as set forth by ACDIS, AAPC, and AHIMA
• Maintain strict confidentiality of all patient information in accordance with HIPAA
• Demonstrate understanding of the business of healthcare: DRG payer issues, audit risks, documentation opportunities, quality metrics, hierarchical condition categories
• Work closely with the client, co-workers, and management to meet the specific needs of each assignment in alignment with core values
• Effectively utilize computer software based on the specific client requirements

BENEFITS:

We offer an excellent salary, full benefits package including 401(k) with company match, medical, dental, vision, life, short/long term disability insurance, and PTO policy.

PHYSICAL DEMANDS OF THE ESSENTIAL FUNCTIONS:

Sitting, talking, hearing and near vision are required over 90% of the time. Feeling is required over 90% of the time and reaching is required about 50% of the time. The ability to travel to field sites may be required up to 15% of the time.

WORKING CONDITIONS WHILE PERFORMING ESSENTIAL FUNCTIONS:

Over 90% of the time is spent indoors, with protection from weather conditions. Exposure to noise levels that may be distracting or uncomfortable is present only in unusual situations.

e4health is an equal opportunity employer and will consider all applications without regard to race, color, religion, national origin, ancestry, marital status, veteran status, age, disability, pregnancy, genetic information, gender, sexual orientation, gender identity or any other legally protected category.

Applicants for U.S. based positions with e4health must be legally authorized to work in the United States. Verification of employment eligibility will be required at the time of hire. Visa sponsorship is not available for this position.

Requirements

REQUIRED QUALIFICATIONS:

• 3+ years of clinical documentation experience
• Current RN license
• Strong analytical skills to clinically evaluate the medical record
• Ability to use a PC for medical record review along with proficiency utilizing Microsoft products (Excel, Word, Outlook)
• Ability to communicate effectively with e4health management and clients

PREFERRED QUALIFICATIONS:

• CCDS or CDIP certification
• BSN, in addition to RN license, is preferred