Clinical Documentation Improvement Specialist (REMOTE)

Ohio State University Wexner Medical Center; Ohio; Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare organization is seeking a Clinical Documentation Improvement Specialist to enhance the quality of medical record documentation. This remote position requires a Bachelor's Degree in Nursing and relevant experience. The role focuses on improving documentation to support coding processes and ensure compliance with guidelines.

Qualifications

• 2 years of relevant experience required.
• 2-4 years of relevant experience preferred.

Responsibilities

• Conduct concurrent review of inpatient medical records.
• Identify opportunities for improving medical record documentation.
• Assist healthcare providers in patient care documentation.

Skills

Clinical Documentation

Quality Improvement

Education

Bachelor's Degree in Nursing

Job description

Clinical Documentation Improvement Specialist (REMOTE)

Scope of Position
The Clinical Documentation Improvement Specialist (CDIS) is a nurse or other clinically qualified individual who is responsible for concurrent review of inpatient medical records to identify opportunities for improving the quality of medical record documentation. Opportunities include identification of cases where diagnoses and procedures are either absent, not stated in appropriate terminology, or are not appropriately recorded. The CDIS will confer with the appropriate caregiver on the additional documentation that may be required. The Documentation Specialists goal is to achieve a complete medical record by the time of patient discharge in order to ensure quality documentation that reflect the patients diagnoses, treatments, and severity of illness, and to facilitate and enhance the coding and DRG assignment process.

Position Summary
This position supports initiatives to improve the quality of documentation by all caregivers within the Ohio State University Health System with specific emphasis on improving documentation to support the coding process which ultimately improves the organizations performance on quality measures and on the Case Mix Index (CMI) which is critical to the financial health of the organization. The CDIS follows The Joint Commission (TJC), Medicare and third party payer documentation guidelines and the official guidelines for assigning ICD- 10-CM diagnosis and procedure codes in efforts to continually improve the quality of medical record documentation. The CDIS provides assistance to the attending physician and other health care providers in the patient care documentation process.

MINIMUM REQUIRED QUALIFICATIONS
Bachelor's Degree in Nursing. Registered Nurse. 2 years of relevant experience required. 2-4 years of relevant experience preferred.

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