CDI Consultant: Clinical Documentation Expert

e4health; Pittsburgh (Allegheny County); On-site; USD 75,000 - 95,000; Full time

Benefits offered by this job

401(k) with company match

Medical insurance

Dental insurance

Vision insurance

Life insurance

Disability insurance

PTO

Job summary

e4health is seeking a Clinical Documentation Integrity (CDI) Consultant to review patient records and ensure accurate documentation reflecting severity and complexity. You will collaborate with providers and coders to reflect true chart data and educate key stakeholders.

Responsibilities include reviewing records, initiating queries, and adhering to ACDIS/AAPC/AHIMA guidelines while protecting patient confidentiality. Maryland APR-DRG experience is a plus, and travel may be required.

Qualifications

• 3+ years of clinical documentation experience.
• Current RN license.
• 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.
• Maryland APR-DRG experience preferred.

Responsibilities

• 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.

Skills

Communication skills

PC-based medical record review

Ability to work with providers and cod

Education

Registered Nurse license

Tools

Microsoft Excel

Microsoft Word

Outlook

Job description

e4health is seeking a Clinical Documentation Integrity (CDI) Consultant to review patient records and ensure accurate documentation reflecting severity and complexity. You will collaborate with providers and coders to reflect true chart data and educate key stakeholders.

Responsibilities include reviewing records, initiating queries, and adhering to ACDIS/AAPC/AHIMA guidelines while protecting patient confidentiality. Maryland APR-DRG experience is a plus, and travel may be required.