CDQI Nurse: Elevate Documentation & Coding Quality

Executive Staff Recruiters / ESR Healthcare; United States; Remote; USD 55,000 - 65,000; Full time

Job summary

ESR Healthcare is seeking a Clinical Documentation Improvement (CDI) Specialist to elevate medical record documentation accuracy and coding quality. You will review inpatient records, query physicians for clarification, and collaborate with care teams to ensure appropriate reimbursement and DRG assignments.

Ideal candidates have 3+ years CDI experience, 3+ years of clinical experience in an academic medical center, and an RN license with a Bachelor's in Nursing.

Qualifications

• 3+ years of CDI experience.
• 3+ years of clinical experience in an academic medical center.
• RN license with Bachelor's in Nursing.
• CCDS or CDIP certification required.
• Must pass a CDI skills competency assessment.
• Must be able to accommodate a min of 15 hours per week.

Responsibilities

• Conduct timely, accurate documentation reviews for selected inpatient records, addressing inadequate or conflicting documentation.
• Collaborate with physicians to ensure appropriate reimbursement and clinical severity for DRG-based payer patients.
• Demonstrate understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix index, secondary diagnoses, and procedure impact on DRG.
• Improve coding specificity by educating physicians and caregivers on clear documentation throughout a patient’s stay.
• Follow AHA guidelines and coding clinics for accurate coding and documentation to ensure compliance.
• Query physicians regarding missing, unclear, or conflicting health record documentation to obtain necessary details.
• Maintain daily production logs for evaluation, tracking cases reviewed, queries placed/responded, etc.
• Perform follow-up reviews to confirm recorded points of clarification in the medical record.
• Ensure confidentiality of all files, documents, and records.
• Meet or exceed production and quality metrics.

Skills

CDI experience

Clinical experience

Education

RN license + Bachelor's in Nursing

Job description

ESR Healthcare is seeking a Clinical Documentation Improvement (CDI) Specialist to elevate medical record documentation accuracy and coding quality. You will review inpatient records, query physicians for clarification, and collaborate with care teams to ensure appropriate reimbursement and DRG assignments.

Ideal candidates have 3+ years CDI experience, 3+ years of clinical experience in an academic medical center, and an RN license with a Bachelor's in Nursing.