Clinical Documentation Improvement Specialist

UPMC; United States; Remote; USD 60,000 - 80,000; Full time

Job summary

UPMC is seeking a Clinical Documentation Improvement Specialist to enhance clinical documentation through collaboration with healthcare teams. This remote role involves evaluating medical records and ensuring accurate documentation to reflect the severity of illness for inpatients. The position requires strong communication skills and experience in clinical documentation improvement.

Qualifications

• Experience as a CDI Specialist required.
• Understanding of clinical documentation and coding.

Responsibilities

• Participate in clinical documentation improvement initiatives.
• Communicate with physicians regarding documentation.
• Evaluate medical records and provide clinical evaluations.

Skills

Clinical Documentation Improvement

Communication

Data Presentation

Education

CDI Specialist Certification

Job description

UPMC Corporate Revenue Cycle is hiring a Clinical Documentation Improvement Specialist to join our coding team. This position will be a work-from-home position working Monday through Friday during normal business hours.

The Clinical Documentation Specialist (CDS) facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the healthcare team to ensure appropriate clinical severity is captured for the level of services rendered to all inpatients.

If you are ready to take the next step in your coding career and have experience as a CDI Specialist, look no further!

Responsibilities:

• Participating at the organizational level in clinical documentation improvement initiatives
• Communicate with physicians, face-to-face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of the severity of illness
• Preparing trended data for presentation one-on-one and small to medium groups of physicians
• Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team
• Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team
• Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans