CDI Consutlant - Healthcare Performance Improvement

City of Gallatin; United States; Remote; USD 70,000 - 95,000; Full time

Job summary

A leading healthcare organization seeks a Consultant who will enhance clinical documentation through education and collaboration. This mid-level position requires a motivated professional with a strong background in Clinical Documentation Improvement, particularly in a hospital setting. The successful candidate will work closely with healthcare teams to ensure accuracy in clinical records, facilitate documentation improvements, and drive performance outcomes.

Qualifications

• 4-7 years of experience as a Clinical Documentation Improvement Specialist within a hospital setting.
• Currently licensed as a Registered Nurse, with a strong understanding of clinical workflow.
• ACDIS or AHIMA certification preferred.

Responsibilities

• Review inpatient medical records for identified payer populations.
• Analyze clinical information to identify potential gaps in physician documentation.
• Facilitate modifications to clinical documentation through interaction with physicians and nursing staff.

Skills

Analytical

Critical Thinking

Communication

Problem Solving

Education

RN, BSN, or Health Information Management degree

Tools

MS Office applications

EPIC

MEDITECH

Job description

BRG’s Healthcare Performance Improvement practice works with healthcare providers to identify and implement measurable and sustainable financial, clinical, and operational performance improvements. We combine comprehensive expertise, experience, and analytics to deliver data-driven, innovative approaches to help hospitals, health systems, academic medical centers, and other providers tackle their most complex problems. We have assessed and implemented nearly $1 billion in cost savings and revenue improvement for our diverse set of clients over the last ten years.

TheConsultantposition is a mid level consulting staff position. This position requires a highly motivated problem solver with strong analytical ability and a desire to advance within the organization. An individual with an entrepreneurial spirit and an ability to apply creative solutions is a natural fit for this position. The Consultant is an integral part of the CDI team and works closely with the client’s CDI team, supporting classroom education and mentoring. They are responsible for ensuring the successful transfer of CDI best practices from the consulting team to the client team. The Consultant also facilitates accurate documentation for severity of illness (SOI) and quality in the medical record, which involves extensive record review and interaction with physicians, health information management professionals, coding professionals, and nursing staff.

Responsibilities:
-Review inpatient medical records for identified payer populations on admission and throughout hospitalization.
- Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.
- Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality measures, and patient safety indicators (PSI).
- Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses, and ancillary staff.
- Work collaboratively with the coding staff to assure documentation of discharge diagnoses and comorbidities are a complete reflection of the patient’s clinical status and care.
- Develop and implement plans for education of physician, nursing, and ancillary staff on documentation improvement.

Candidate must be able to submit verification of his/her legal right to work in the U.S., without company sponsorship.

• 4-7 years of experience as a Clinical Documentation Improvement (CDI) Specialist within a hospital setting or as a CDI consultant, or a combination thereof.
• RN, BSN, or Health Information Management degree required.
• Currently licensed as a Registered Nurse – ICU, OR, ED specialty preferred, with a strong understanding of clinical workflow.
• Minimum 2 years of inpatient coding experience with ICD-10 CM/PCS preferred.
• ACDIS or AHIMA certification preferred.
• Strong knowledge of CDI principles, including the ability to audit medical records, teach CDI principles to clinicians, coders, and other healthcare professionals.
• Experience in clinical documentation improvement, coding, audit, or Health Information Management.
• Ability to assist with the development of CDI and HIM training and consulting tools and methodologies.
• Excellent organizational, analytical, and writing skills, with the ability to demonstrate critical thinking and problem-solving.
• Strong verbal and written communication skills, with excellent public speaking and presentation abilities.
• Effective communication with physicians, coding professionals, and other stakeholders.
• Knowledge of regulatory guidelines and Medicare Part A, MS-DRG, and/or APR-DRG payment methodologies.
• Ability to pass a written clinical competency assessment.
• Familiarity with hospital systems such as EPIC, MEDITECH, or similar platforms is desired.
• Strong proficiency in MS Office applications, including Word, PowerPoint, Excel, and Outlook.
• Excellent time management skills and the ability to handle multiple priorities effectively.