Clinical Documentation Improvement/Integrity Specialist

RevCure LLC; United States; On-site; USD 70,000 - 90,000; Full time

Job summary

RevCure LLC seeks a Clinical Documentation Improvement/Integrity (CDI) Specialist to ensure high-quality documentation in patient records and educate the care team on current guidelines. The role involves overseeing workflows, generating strategic reports, training staff, and reviewing records to support appropriate illness severity, risk of mortality, and care complexity.

Essential duties include rapid initial reviews within 24 hours of admission, daily follow-ups, and close collaboration with

Qualifications

• Minimum of two years of concurrent inpatient CDI experience.

Responsibilities

• Initial Review: Conducts medical record reviews within 24 hours of patient admission to assign diagnoses, procedures, and evaluate severity of illness and mortality risk.
• Follow-Up Reviews: Performs follow-up reviews every 1 day to finalize MS-DRG/APR-DRG assignments.
• Query Generation: Formulates compliant queries for missing or unclear documentation and follows up until resolution.
• Concurrent Collaboration: Works with care providers, case managers, nursing staff, and other ancillary staff to resolve documentation issues before discharge.
• Data Management: Enters facility-specific data to dashboards in accordance with workflow assignments.
• Attend Meetings & Calls: Attends in person when applicable and conference calls for required CDI education, Client and RevCure meetings.
• Collaboration with Client’s departments: Collaborates with Client’s HIM leadership and coding staff to promote complete and accurate clinical documentation and correct negative trends.
• Interdepartmental Communication: Communicates with the Auditing team to resolve documentation/coding mismatches and collaborates with the Denials team to formulate queries for appeals and training.
• Education and Training: Works with physicians to provide continuous education to improve their clinical documentation skills and offers CDI support to leadership and staff.

Skills

CCDS/CCS/CDIP

Education

MD or MD equivalent (US/Foreign)

Job description

• Required Education: US or Foreign Medical Graduate, MD or MD equivalent
• Required Experience: Minimum of two years of concurrent inpatient Clinical Documentation Improvement (CDI) experience.
• Required Certifications: one of the following: CCDS, CCS, CDIP

Job Summary

The Clinical Documentation Improvement/Integrity (CDI) Specialist ensures the quality and completeness of clinical documentation in medical records. This role involves educating the patient care team on the most current documentation guidelines, overseeing department workflow and metrics, creating strategic reports, training staff, and reviewing medical records to ensure accurate physician documentation. The goal is to support appropriate severity of illness, risk of mortality, and care complexity for patients.

Essential Duties and Responsibilities

• Initial Review: Conducts medical record reviews within 24 hours of patient admission to assign diagnoses, procedures, and evaluate severity of illness and mortality risk.
• Follow-Up Reviews: Performs follow-up reviews every 1 day to finalize MS-DRG/APR-DRG assignments.
• Query Generation: Formulates compliant and quality quantitative and qualitative queries for missing or unclear documentation and to obtain additional information as needed. Follow-up on open queries until resolution.
• Concurrent Collaboration: Works with care providers, case managers, nursing staff, and other ancillary staff to resolve documentation issues before discharge.
• Data Management: Enters facility-specific data to dashboards in accordance with workflow assignments.
• Attend Meetings & Calls: Attends in person when applicable and conference calls for any required CDI education, Client and RevCure meetings.
• Collaboration with Client’s departments: Collaborates with Client’s HIM leadership and coding staff to promote complete and accurate clinical documentation and correct negative trends.
• Interdepartmental Communication: Communicates with the Auditing team to resolve documentation/coding mismatches and complete retrospective query requests. Also collaborates with the Denials team to formulate queries for the appeals process and serves as the link between facility care providers and staff for real-time training and education to improve coding processes and denials prevention.
• Education and Training: Work closely with physicians to provide continuous education to improve their clinical documentation skills (coding accuracy, documentation requirements, and regulatory compliance). Offers CDI support and training/education hospital leadership and other ancillary staff on a continuous basis.

Professional Development

• Stay Updated: Keeps current with AHA Official Coding and Reporting Guidelines, CMS directives, and other agency directives for ICD-10 CM and PCS.
• Review Coding Clinic: Regularly reviews AHA Coding Clinics to stay current with CDI practices.
• Certifications: Strives to obtain additional industry certifications

Knowledge, Skills, Abilities

• Teamwork & Commitment: Display teamwork and commitment in daily duties.
• Initiative & Time Management: Demonstrate initiative and discipline in time management and medical record review. Excellent organizational skills for efficient workflow.
• Software system/EMR: Requires proficiency in using 3M coding software, Cerner and EPIC EMRs.
• Independence: Ability to work independently in a virtual or facility setting.
• Critical Thinking & Communication: Strong critical thinking, problem-solving, deductive reasoning skills, and effective written and verbal communication.
• Coding Compliance: Knowledge of coding compliance and regulatory standards. Apply coding conventions, official guidelines, and Coding Clinic advice.
• Documentation Strategies: Understand and communicate documentation strategies, recognize improvement opportunities, and formulate compliant queries.
• Auditing & Monitoring: Maintain an auditing and monitoring program to measure the query process.
• Issue Resolution: Resolve issues effectively and provide recommendations and solutions.
• Education & Mentorship: Explain processes clearly, educate others, mentor CDI team, and represent CDI in meetings.

Vaccinations/Screenings

Candidates may be required to obtain and provide confirmation of required vaccinations and screenings before employment per Client’s request, including but not limited to, COVID-19 and influenza vaccinations (as well as any future required vaccines and screenings) and toxicology/drug screenings.