Clinical Documentation Improvement Specialist *Must Have Active RN License*

Davita Inc.; Austin (TX); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare company seeks a CDI Specialist to ensure quality documentation and accurate reimbursement. The role involves reviewing patient records, interacting with providers, and maintaining compliance with clinical documentation guidelines. This fully remote position requires at least 3 years of clinical experience.

Benefits

Medical, dental & vision

401(k) Retirement Plan

Life Insurance

Short and long-term disability

Health Spending Account

Transportation benefits

Employee Assistance Program

Time Off/Leave

Qualifications

• Minimum of 3 years of recent clinical bedside experience in ICU, Tele, Med/Surg, or ED setting.

Responsibilities

• Review patient records for documentation accuracy and compliance.
• Conduct focused reviews in areas identified by CDI leadership.
• Draft and submit compliant queries to providers.

Skills

Independent judgment

Critical thinking

Clinical documentation review

Job description

*Job Overview: *
As our CDI Specialist, you will be responsible for supporting and facilitating the overall quality of medical record documentation by improving the completeness, accuracy, and reliability of clinical documentation. Every day, you will obtain appropriate clinical documentation through an extensive review of provider, nursing, ancillary, and other patient caregivers' documentation, to ensure that appropriate documentation and reimbursement is received for the level of services rendered to patients. On an ongoing basis, the CDI Specialist is responsible for supporting the direction and focus of education for providers and the coding staff within their assigned scope of work. The CDI Specialist must exercise independent judgment, critical thinking, and ability to work independently while interpreting and following CMS guidelines, organizational policies, and procedures. To thrive in this role, you must have a minimum of 3 years of recent clinical bedside experience in the ICU, Tele, Med/Surg, or ED setting.
*Here's what you will experience working as a CDI Specialist:*
* Review patient records for the assigned patient population to evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG or APR-DRG assignment in compliance with coding guidelines and regulatory requirements.
* Conduct focused reviews in areas identified by CDI leadership: mortality reviews, PSI reviews, as well as other identified projects.
* Serve as a subject matter expert and authoritative resource on interpretation and application of CDI practices, coding rules, and regulations and conduct risk assessments of potential and detected compliance deficiencies, as well as documentation improvement opportunities.
* Draft and submit compliant queries to providers in compliance with industry compliance standards; conduct follow-up reviews of clinical documentation to ensure points of clarification with providers have been accurately recorded in the patient's medical record.
* Reconcile reviewed cases with final coding and communicate with coders to identify the root cause of CDI-Coder final DRG mismatch and resolution of incongruence as part of ongoing quality control efforts.
*Pay and Benefits*
The pay range for this position is $35.00 - $45.00/hr.
Eligibility requirements apply to some benefits and may depend on your job
classification and length of employment. Benefits are subject to change and may be
subject to specific elections, plan, or program terms. If eligible, the benefits
available for this temporary role may include the following:
* Medical, dental & vision
* Critical Illness, Accident, and Hospital
* 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available
* Life Insurance (Voluntary Life & AD&D for the employee and dependents)
* Short and long-term disability
* Health Spending Account (HSA)
* Transportation benefits
* Employee Assistance Program
* Time Off/Leave (PTO, Vacation or Sick Leave)
*Workplace Type*
This is a fully remote position.
*Application Deadline*
This position is anticipated to close on Jun 16, 2025.
About TEKsystems and TEKsystems Global Services

We're a leading provider of business and technology services. We accelerate business transformation for our customers. Our expertise in strategy, design, execution and operations unlocks business value through a range of solutions. We're a team of 80,000 strong, working with over 6,000 customers, including 80% of the Fortune 500 across North America, Europe and Asia, who partner with us for our scale, full-stack capabilities and speed. We're strategic thinkers, hands-on collaborators, helping customers capitalize on change and master the momentum of technology. We're building tomorrow by delivering business outcomes and making positive impacts in our global communities. TEKsystems and TEKsystems Global Services are Allegis Group companies. Learn more at TEKsystems.com.


The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.