CDI Specialist: Elevate Clinical Documentation

Med-Metrix; Parsippany-Troy Hills (NJ); Hybrid; USD 85,000 - 120,000; Full time

Job summary

Med-Metrix is seeking a Clinical Documentation Integrity Specialist to ensure inpatient documentation accurately reflects illness severity, complexity of care, and risk of mortality for proper coding and reimbursement. The role involves concurrent chart reviews, collaboration with physicians, and data-driven improvement initiatives.

The ideal candidate has RN/MD/DO/NP/PA licensure, CCDS/CDIP certifications, and a strong grasp of ICD-10 guidelines, DRG systems, and CDI tools.

Qualifications

• BSN/PA/NP/Doctorate in a medically related field is required.
• Active RN/MD/DO/NP/PA license required.
• Certification CCDS and/or CDIP recommended.
• High school diploma or equivalent required.
• RN license preferred in practice.

Responsibilities

• Analyze medical records to identify incomplete or inaccurate documentation.
• Perform concurrent chart reviews to ensure accurate coding and reimbursement.
• Clarify documentation with physicians and healthcare team for accurate DRG assignment.
• Monitor documentation performance and identify improvement opportunities.
• Collaborate with clinicians and coders to ensure compliant coding practices.
• Provide training on documentation best practices and coding guidelines.

Skills

Interpersonal skills

Problem solving

Communication skills

Attention to detail

Education

BSN/PA/NP/Doctorate in a related field

RN/MD/DO/NP/PA license

CCDS or CDIP certification

High school diploma or equivalent

RN license preferred

Tools

MS Office

CDI tools

Encoder/CDI workflow tools

Reporting tools

Job description

Med-Metrix is seeking a Clinical Documentation Integrity Specialist to ensure inpatient documentation accurately reflects illness severity, complexity of care, and risk of mortality for proper coding and reimbursement. The role involves concurrent chart reviews, collaboration with physicians, and data-driven improvement initiatives.

The ideal candidate has RN/MD/DO/NP/PA licensure, CCDS/CDIP certifications, and a strong grasp of ICD-10 guidelines, DRG systems, and CDI tools.