Clinical Documentation Integrity Specialist

e4health; United States; Remote; USD 70,000 - 95,000; Full time

Benefits offered by this job

401(k) with company match

Medical, dental, vision benefits

PTO

Job summary

e4health is seeking a Clinical Documentation Integrity (CDI) Consultant to review patient records for accuracy and completeness, ensuring documentation reflects illness severity and complexity. You will collaborate with providers and coders to reflect true chart data and educate clinicians on documentation opportunities.

Responsibilities include performing chart reviews, initiating queries, adhering to ACDIS/AHIMA guidelines, and maintaining HIPAA confidentiality while supporting healthcare

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.

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 core values.
• Effectively utilize computer software based on the specific client requirements.

Skills

Analytical skills

PC proficiency

Communication skills

Clinical documentation

Healthcare familiarity

Education

RN license

Graduate of medical school with 5+ years of acute care experience

Tools

Microsoft Excel

Microsoft Word

Microsoft Outlook

Job description

e4health is seeking a Clinical Documentation Integrity (CDI) Consultant to review patient records for accuracy and completeness, ensuring documentation reflects illness severity and complexity. You will collaborate with providers and coders to reflect true chart data and educate clinicians on documentation opportunities.

Responsibilities include performing chart reviews, initiating queries, adhering to ACDIS/AHIMA guidelines, and maintaining HIPAA confidentiality while supporting healthcare