Clinical Documentation Integrity Expert

Med-Metrix, LLC; Parsippany-Troy Hills (NJ); Remote; USD 95,000 - 115,000; Full time

Job summary

Med-Metrix, LLC is seeking a Clinical Documentation Integrity Specialist to ensure accurate inpatient documentation for proper coding and reporting. You will perform concurrent chart reviews, validate severity of illness and risk of mortality, and collaborate with physicians, nurses, and coding teams to improve documentation accuracy.

The role requires 3+ years in inpatient CDI and a current RN license; CCDS/CDIP certification is highly valued.

Qualifications

• Minimum 3 years in inpatient clinical documentation improvement.
• Minimum 5 years of nursing in adult acute care (med/surg/ICU/ER/PACU).
• CCD S/CDIP certification preferred; RN license required.
• ICD-10 guidelines and DRG knowledge essential.
• Strong analytical thinking, problem solving and communication skills.

Responsibilities

• Analyze medical records to identify incomplete or inaccurate documentation.
• Conduct concurrent chart reviews to validate severity of illness and coding accuracy.
• Collaborate with physicians and staff to obtain missing information.
• Support coders by ensuring documentation supports codes and guidelines.
• Provide training on documentation practices, coding guidelines, and compliance.

Skills

Clinical documentation

HIPAA compliance

Data analytics

Communication skills

Independent worker

Education

Registered Nurse license

CCDS/CDIP certification

Tools

Encoder/CDI tools

Microsoft Office

Job description

Med-Metrix, LLC is seeking a Clinical Documentation Integrity Specialist to ensure accurate inpatient documentation for proper coding and reporting. You will perform concurrent chart reviews, validate severity of illness and risk of mortality, and collaborate with physicians, nurses, and coding teams to improve documentation accuracy.

The role requires 3+ years in inpatient CDI and a current RN license; CCDS/CDIP certification is highly valued.