CDI Specialist: Elevate Clinical Documentation Integrity

Sky Lakes; Klamath Falls, Northern (OR, KY); Hybrid; USD 80,000 - 126,000; Full time

Job summary

Ultipro in Oregon is seeking a Clinical Documentation Improvement Specialist to join the Clinical Doc Integrity program. This full-time, on-site role focuses on reviewing records to improve physician documentation for accurate MS-DRG assignment and MCC/CC capture.

The ideal candidate has a strong clinical background with at least five years of hospital RN experience or NP/PA with similar exposure, plus proficiency with EHR systems and Microsoft Office.

Qualifications

• Minimum 5 years recent hospital experience as RN; NP/PA routes require 4 years clinical experience.
• Current Oregon RN/NP/LPN/PA license is required.
• Experience with CDMP documentation strategies and CDI processes is preferred.

Responsibilities

• Identify records for review based on CDI priorities and LOS, diagnoses, and strategies.
• Review records to identify opportunities for improved physician documentation for MS-DRG capture.
• Achieve higher specificity and accuracy in documentation through clarifications.
• Communicate with physicians to obtain clarifications in a timely, compliant manner.
• Monitor CDI processes and ensure activities meet program goals.
• Collaborate with Inpatient CDI Manager to optimize high-volume/high-risk diagnoses workflows.
• Coordinate with HIM staff to resolve documentation discrepancies.

Skills

Clinical experience

Organization

Analytical skills

Time management

Communication with physicians

CDMP / documentation strategies

Education

RN license

NP license

PA license

Tools

Microsoft Office

Electronic Health Records

Job description

Ultipro in Oregon is seeking a Clinical Documentation Improvement Specialist to join the Clinical Doc Integrity program. This full-time, on-site role focuses on reviewing records to improve physician documentation for accurate MS-DRG assignment and MCC/CC capture.

The ideal candidate has a strong clinical background with at least five years of hospital RN experience or NP/PA with similar exposure, plus proficiency with EHR systems and Microsoft Office.