Clinical Documentation Improvement Specialist

Business Integra Inc; United States; Remote; USD 60,000 - 80,000; Full time

Job summary

Join a forward-thinking healthcare team as a Clinical Documentation Improvement Specialist, where your expertise will enhance patient care and compliance. In this vital role, you will ensure the accuracy of clinical documentation, collaborate with healthcare providers, and conduct audits to elevate documentation practices. Your strong analytical skills and understanding of coding standards will be essential in improving documentation quality. This innovative firm offers a remote work environment, allowing you to make a significant impact in the healthcare sector while enjoying a flexible schedule. If you're passionate about quality improvement and patient care, this opportunity is perfect for you.

Qualifications

• Minimum 2-3 years of experience as a Clinical Documentation Specialist.
• Strong understanding of clinical terminology and coding systems.

Responsibilities

• Review clinical documentation for accuracy and completeness.
• Collaborate with providers to improve documentation quality.
• Provide training on documentation techniques.

Skills

ICD-10 Coding

Clinical Documentation

Analytical Skills

Communication Skills

Utilization Review

Education

Medical Degree or RN License

CCDS or CCDIP Certification

Tools

eClinicalWorks

Epic

Job description

Job Overview
We are seeking a dedicated and detail-oriented Clinical Documentation Improvement Specialist to join our healthcare team. This role is essential in ensuring the accuracy and completeness of clinical documentation, which is vital for patient care, compliance, and reimbursement processes. The ideal candidate will have a strong understanding of clinical terminology, coding systems, and healthcare regulations.

Required Qualifications:

Licensure/Education: IMG with a medical degree or RN license.
Experience: Minimum 2-3 years of Clinical Documentation Specialist experience.
Preferred Specialties: Experience in OBGYN, Pediatrics, Inpatient Psychiatry.
Preferred Skills: Quality-based reviews, mortality reviews, and risk adjustment tool experience.
Certifications: CCDS or CCDIP required.
Key Competencies: Strong communication skills, ability to work effectively in a remote team environment.

Recruitment Process:
Application review
Assessment - proctored assessment with the team assistant
Interview
Offer and onboarding

COVID-19 Vaccine (Facility Guideline):Required + Booster - Medical/Religious Exemptions only

Responsibilities

• Review and analyze clinical documentation to ensure it accurately reflects the patient's condition and care provided.
• Collaborate with healthcare providers to clarify documentation discrepancies and improve overall documentation quality.
• Conduct audits of medical records to identify areas for improvement in clinical documentation practices.
• Provide education and training to staff on proper documentation techniques and coding guidelines.
• Utilize electronic health record systems such as eClinicalWorks and Epic to enhance documentation processes.
• Stay updated on ICD-10 coding updates, Medicare regulations, and best practices in clinical documentation improvement.
• Participate in discharge planning and utilization review processes to ensure appropriate patient care transitions.

Skills

• Proficient understanding of ICD-10 coding standards and guidelines.
• Experience with utilization review processes and discharge planning.
• Familiarity with outpatient settings, home care services, and operating room (OR) environments.
• Strong analytical skills with the ability to interpret complex medical information.
• Excellent communication skills for effective collaboration with healthcare professionals.
• Knowledge of electronic health record systems, particularly eClinicalWorks and Epic.
• Understanding of primary care practices and Medicare requirements.

Job Type: Contract

Pay: $60.98 - $65.92 per hour

Expected hours: 40 per week

Schedule:

• 8 hour shift

License/Certification:

• CCDS or CCDIP (Required)

Work Location: Remote