Clinical Documentation Improvement Specialist (FT- 1.0 FTE, Remote)

Bozeman Health; United States; Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a Clinical Documentation Improvement Specialist to enhance the quality and accuracy of medical documentation. This remote position involves conducting concurrent reviews of inpatient records, ensuring compliance with coding principles, and collaborating with healthcare providers. The ideal candidate will possess a Bachelor's degree in Nursing or an equivalent medical qualification, along with relevant coding certifications. Join a forward-thinking organization that values professional growth and offers a supportive environment for enhancing healthcare documentation practices.

Qualifications

• Bachelor's degree in Nursing or equivalent medical program required.
• At least one coding or documentation certification required.

Responsibilities

• Conduct concurrent reviews of inpatient records and assign diagnoses.
• Collaborate with healthcare professionals for accurate documentation.

Skills

Clinical Documentation Improvement

Coding Principles

Communication Skills

Organizational Skills

Judgment and Professionalism

Education

Bachelor's degree in Nursing (RN)

Medical Degree (MD, DO, NP)

Tools

Epic

3M 360 Encoder

Job description

Clinical Documentation Improvement Specialist (FT- 1.0 FTE, Remote)

Join to apply for the Clinical Documentation Improvement Specialist (FT- 1.0 FTE, Remote) role at Bozeman Health

Position Summary:

The Clinical Documentation Improvement Specialist (CDIS) conducts concurrent reviews of inpatient medical records to enhance the quality, accuracy, and completeness of documentation. Utilizing clinical expertise and current coding systems (ICD-10-CM & PCS), the CDIS ensures proper code assignment and alignment with the patient’s clinical condition and care provided. The role involves collaborating with providers through education and the physician query process to support severity of illness, quality metrics, and regulatory compliance. Additionally, the CDIS maintains expertise in coding principles, government regulations, and third-party requirements while serving as a resource for clinicians, coders, and Revenue Cycle teams.

Approved Remote States:

• Arizona
• Florida
• Georgia
• Idaho
• Iowa
• South Dakota
• Texas
• South Carolina
• Wisconsin
• North Carolina
• Montana

Minimum Qualifications:

Required:

• Bachelor's degree in Nursing (RN) or completion of an accredited or equivalent international medical program.
• Current licensure as a Registered Nurse (RN) or a graduate of an accredited advanced medical program (MD, DO, NP, MBBS, or equivalent).
• At least one of the following professional coding or documentation certifications:
• Certified Coding Specialist (CCS)
• Certified Clinical Documentation Specialist (CCDS)
• Certified Documentation Improvement Practitioner (CDIP)
• Registered Health Information Administrator (RHIA)
• Registered Health Information Technician (RHIT)

Preferred:

• Three (3) years of experience in one of the following areas:
• Medical/Surgical or Critical Care nursing.
• Clinical Documentation Improvement (CDI) or Inpatient Coding in an acute care setting.
• Experience with Epic and 3M 360 Encoder systems.

Essential Job Functions:

In addition to other responsibilities, employees must complete all required education on time as per DNV, Bozeman Health policy, and registry requirements. Key functions include:

• Ensure accurate, ethical, and complete coding following current guidelines when assigning DRGs, diagnoses, and procedures.
• Conduct concurrent reviews of inpatient records, assign diagnoses, procedures, and DRGs.
• Follow CDI processes for physician queries, DRG reconciliation, and resolving documentation issues before discharge.
• Collaborate with healthcare professionals to ensure documentation reflects severity of illness, mortality risk, and services provided.
• Use clinical documentation systems (e.g., 3M 360, Epic) to identify improvement opportunities.
• Identify and escalate data integrity issues related to coding, CDI, or EHR systems.
• Maintain HIPAA compliance and confidentiality.
• Participate in meetings, training, and educational initiatives.
• Provide education and consultation to coders and clinicians for documentation and coding accuracy.
• Recommend process improvements within CDI and coding workflows.
• Generate reports to monitor CDI effectiveness and documentation trends.
• Stay updated on CMS regulations and industry best practices.
• Meet productivity and quality standards and complete assigned projects.

Knowledge, Skills, and Abilities:

• Sound judgment, professionalism, and confidentiality.
• Ability to work effectively in a busy and stressful environment.
• Strong communication skills.
• Organizational and prioritization skills.

Schedule Requirements:

• Regular attendance required.
• Potential for extended hours, weekends, and after-hours shifts.
• On-call responsibilities may be necessary.

Physical Requirements:

• Lifting rarely (up to 30 pounds).
• Sitting continuously, standing and walking occasionally.
• Climbing, twisting, bending, reaching, pushing, pulling, and fine motor skills as specified.
• Visual and cognitive skills required continuously.
• Exposure to biological, chemical, and infectious hazards is rare.

The above describes the general nature of the work and is not an exhaustive list of duties.