Clinical Documentation Quality Improvement (CDQI) nurse remote

Executive Staff Recruiters / ESR Healthcare; United States; Remote; USD 55,000 - 65,000; Full time

Job summary

ESR Healthcare is seeking a Clinical Documentation Improvement (CDI) Specialist to elevate medical record documentation accuracy and coding quality. You will review inpatient records, query physicians for clarification, and collaborate with care teams to ensure appropriate reimbursement and DRG assignments.

Ideal candidates have 3+ years CDI experience, 3+ years of clinical experience in an academic medical center, and an RN license with a Bachelor's in Nursing.

Qualifications

• 3+ years of CDI experience.
• 3+ years of clinical experience in an academic medical center.
• RN license with Bachelor's in Nursing.
• CCDS or CDIP certification required.
• Must pass a CDI skills competency assessment.
• Must be able to accommodate a min of 15 hours per week.

Responsibilities

• Conduct timely, accurate documentation reviews for selected inpatient records, addressing inadequate or conflicting documentation.
• Collaborate with physicians to ensure appropriate reimbursement and clinical severity for DRG-based payer patients.
• Demonstrate understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix index, secondary diagnoses, and procedure impact on DRG.
• Improve coding specificity by educating physicians and caregivers on clear documentation throughout a patient’s stay.
• Follow AHA guidelines and coding clinics for accurate coding and documentation to ensure compliance.
• Query physicians regarding missing, unclear, or conflicting health record documentation to obtain necessary details.
• Maintain daily production logs for evaluation, tracking cases reviewed, queries placed/responded, etc.
• Perform follow-up reviews to confirm recorded points of clarification in the medical record.
• Ensure confidentiality of all files, documents, and records.
• Meet or exceed production and quality metrics.

Skills

CDI experience

Clinical experience

Education

RN license + Bachelor's in Nursing

Job description

Clinical Documentation Quality Improvement (CDQI) Specialist, you will play a pivotal role in elevating the impact of our medical record documentation. You will conduct daily evaluations and engage in direct communication with providers to enhance documentation clarity, completeness, and overall medical record quality. By ensuring accurate and comprehensive physician documentation, you will be at the forefront of influencing the precision of code assignment, making a tangible difference in the accuracy of healthcare data. Join us in this critical role where your efforts will have a direct and meaningful impact on the quality and effectiveness of patient care.

What You Will Do:

• Conduct timely, accurate, and complete documentation reviews for selected inpatient records, addressing inadequate or conflicting documentation.
• Collaborate with physicians and caregivers to ensure appropriate reimbursement and clinical severity for DRG-based payer patients.
• Demonstrate understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix index, secondary diagnoses, and procedure impact on DRG.
• Improve coding specificity by educating physicians and caregivers on the importance of clear documentation throughout a patient's stay.
• Follow AHA guidelines and coding clinics for accurate coding and required documentation to ensure compliance.
• Query physicians regarding missing, unclear, or conflicting health record documentation to obtain necessary details.
• Maintain daily production logs for evaluation, tracking cases reviewed, queries placed/responded, etc.
• Perform follow-up reviews to confirm recorded points of clarification in the patient's medical record.
• Ensure confidentiality of all files, documents, and records.
• Meet or exceed production and quality metrics.

What You Need to Succeed:

• 3+ years of CDI experience
• 3+ years of clinical experience in an academic medical center
• Registered Nurse license, Bachelor's degree in Nursing
• CCDS or CDIP certification required
• Must pass a CDI skills competency assessment
• Must be able to accommodate a min of 15 hours per week
• Pay ranges for this job title may differ based on location, responsibilities, skills, experience, and other requirements of the role.

The estimated base pay range per hour for this role is:

• $40—$47 USD

To ensure the safety of patients and staff, many of our clients require post-offer health screenings and proof and/or completion of various vaccinations such as the flu shot, Tdap, COVID-19, etc. Any requests to be exempted from these requirements will be reviewed by Datavant Human Resources and determined on a case-by-case basis. Depending on the state in which you will be working, exemptions may be available on the basis of disability, medical contraindications to the vaccine or any of its components, pregnancy or pregnancy‑related medical conditions, and/or religion.

This job is not eligible for employment sponsorship.