Clinical Documentation Improvement Specialist

Santa Barbara Cottage Hospital; United States; Remote; USD 70,000 - 100,000; Full time

Job summary

A leading healthcare provider is seeking a Clinical Documentation Integrity Consultant to review patient medical records, ensuring accurate and complete documentation. This role requires skills in communication and analysis, working closely with healthcare providers and coders to enhance documentation practices.

Benefits

401(k) with company match

Medical, dental, and vision insurance

Life and disability insurance

Paid time off (PTO)

Qualifications

• 2+ years of clinical documentation experience required.
• Current RN license or medical school graduate preferred.
• Ability to analyze and evaluate medical records.

Responsibilities

• Review medical records for complete and accurate documentation.
• Initiate and complete queries to ensure accurate data.
• Adhere to guidelines by ACDIS, AAPC, and AHIMA.

Skills

Analytical skills

Communication

Time management

Organizational skills

Education

RN license

BSN

Medical degree

Tools

Microsoft Excel

Microsoft Word

Microsoft Outlook

Job description

Job Description

At e4health, we Empower Better Health. The e4health Team is on a relentless mission to care for those teams who care for others. We bring our passion, ingenuity, and expertise to every engagement. In joining our Team, we want your help to provide our customers with powerful solutions in the pursuit of quality, integrity, clinical and financial value across healthcare.

Our People make the difference. Serving more than 400 hospitals and health systems nationwide for nearly two decades, e4health provides solutions to tackle the toughest problems in healthcare with unmatched technology, mid-revenue cycle, and operational expertise. e4health solutions streamline clinical, financial, and health information data and workflows, optimize coding, quality, and clinical documentation integrity processes, and address health IT operational challenges to deliver material results for healthcare organizations across the country. Learn more about us at www.e4.health.

POSITION TITLE:	Clinical Documentation Integrity (CDI) Consultant
ROLE TYPE:	Individual Contributor
EMPLOYMENT TYPE:	Non-Exempt

JOB SUMMARY:

The Clinical Documentation Integrity Consultant will provide timely reviews of patient medical records to ensure accurate and complete documentation to reflect the patient’s severity and complexity of illness. The CDI consultant is expected to work with providers and coders to ensure that documentation on the chart reflects the complexity of the patient. The ability to educate and interact with providers is essential.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Review medical records as assigned for complete and accurate documentation of all relevant diagnoses and procedures
• Initiate and complete queries as necessary to reflect accurate data regarding the patient’s inpatient or outpatient visit
• Adhere to guidelines as set forth by ACDIS, AAPC, and AHIMA
• Maintain strict confidentiality of all patient information in accordance with HIPAA
• Demonstrate understanding of the business of healthcare: DRG payer issues, audit risks, documentation opportunities, quality metrics, hierarchical condition categories
• Work closely with the client, co-workers and management to meet the specific needs of each assignment in alignment with Intellis’ core values
• Effectively utilize computer software based on the specific client requirements

REQUIRED QUALIFICATIONS:

• 2+ years of clinical documentation experience
• Current RN license or graduate of medical school with 5+ years of acute care experience preferred; some clients may require RN
• Strong analytical skills to clinically evaluate the medical record
• Ability to use a PC for medical record review along with proficiency utilizing Microsoft products (Excel, Word, Outlook)
• Ability to communicate effectively with e4health management and clients

Preferred Qualifications:

• CCDS or CDIP certification
• BSN, in addition to RN license is preferred

Additional Information

KEY SUCCESS ATTRIBUTES:

• Integrity, passion, and ethics are required
• Demonstrates strong collaboration skills
• Has strong analytic and problem-solving abilities and techniques
• Exhibit consistent initiative with strong drive for results and success
• Demonstrate commitment to a team environment
• Well-developed written, verbal, and presentation communication skills including deep listening and attention to detail
• Ability to self-motivate and self-direct
• Possess strong time management and organizational skills
• Commitment and adherence to company Core Values

CORE COMPETENCIES:

• High level of integrity & ethical judgement
• Communication
• Consistency and Reliability
• Meeting standards

BENEFITS:

We offer an excellent salary, full benefits package including 401(k) with company match, medical, dental, vision, life, & short/long term disability insurance, and PTO policy.

PHYSICAL DEMANDS OF THE ESSENTIAL FUNCTIONS:

Sitting, talking, hearing and near vision are required over 90% of the time. Feeling is required 90% of the time and reaching is required about 50% of the time. The ability to travel to field sites may be required up to 15% of the time.

WORKING CONDITIONS WHILE PERFORMING ESSENTIAL FUNCTIONS:

Over 90% of the time is spent indoors, with protection from weather conditions. Exposure to noise levels that may be distracting or uncomfortable is present in only unusual situations.

e4health is an equal opportunity employer and will consider all applications without regard to race, color, religion, national origin, ancestry, marital status, veteran status, age, disability, pregnancy, genetic information, gender, sexual orientation, gender identity or any other legally protected category.

Applicants for U.S. based positions with e4health must be legally authorized to work in the United States. Verification of employment eligibility will be required at the time of hire. Visa sponsorship is not available for this position.