Lead Clinical Documentation Improvement Specialist (REMOTE)

Ohio State University Wexner Medical Center; Kentucky; Remote; USD 75,000 - 90,000; Full time

Job summary

A prominent healthcare institution in Kentucky is seeking a Clinical Documentation Improvement Analyst 4 to enhance healthcare provider documentation integrity and ensure accurate coding. Candidates must have a nursing degree, active RN license, and relevant CCDS or CDIP certification. This role involves auditing documentation quality and providing essential education to team members. A commitment to ongoing education and compliance with healthcare standards is paramount.

Qualifications

• 6 years of relevant experience required; 6-10 years preferred.
• Experience in Clinical Documentation Integrity Auditing/Education.
• Familiarity with payer compliance.

Responsibilities

• Perform concurrent and retrospective reviews to improve documentation quality.
• Complete audits for query compliance and coding accuracy.
• Develop and provide education for CDI onboarding and ongoing training.

Skills

Excellent communication skills

Team collaboration

Ability to work independently

Proficiency in ICD-10-CM/PCS coding

Knowledge of quality metrics

Education

Bachelors degree in nursing

Active RN license

CCDS or CDIP certification

Tools

Coding applications

Electronic spreadsheets

Job description

Scope of Position

The Clinical Documentation Improvement Analyst 4 (CDI Analyst 4) is responsible for performing concurrent and retrospective 1st line and 2nd level reviews to identify opportunities for improving the quality of medical record documentation. The CDI Analyst 4 completes audits to assess query compliance, coding accuracy, and provider education opportunities. The CDI Analyst 4 develops and provides education to ensure competency and compliance, and functions as a liaison between the CDI department, coding, quality, compliance, clinical providers and organizational leadership.

Position Summary

This position supports initiatives to improve healthcare provider documentation integrity to ensure accurate medical coding within the Ohio State University Health System. The CDI Analyst 4 follows JCAHO, CMS, third party payor documentation guidelines, and the official guidelines for assigning ICD-10 working diagnosis and procedure codes in efforts to continually improve the quality of medical record documentation. The CDI Analyst 4 works closely with CDI Manager to develop, present, and manage education curriculum for CDI onboarding, and continued education for CDI specialists, providers and physician advisors. The CDI Analyst 4 completes second level review for quality measures, clinical validation, and outcomes improvement. CDI Analyst 4 participates in interdisciplinary work groups as subject matter expert to achieve desired outcomes.

Minimum Qualifications

For Hire:

• Bachelors degree in nursing. Registered Nurse. 6 years of relevant experience required. 6-10 years of relevant experience preferred.
• Active RN license
• CCDS (Certified Clinical Documentation Specialist or CDIP (Certified Documentation Improvement Practitioner) certification
• Knowledge and experience in medical information, computer applications, coding applications, work processing, and electronic spreadsheets

Ongoing:

• Maintain RN licensure in good standing
• Maintain CCDS or CDIP certification in good standing
• Experience in Clinical Documentation Integrity Auditing/Education
• Proficiency in ICD-10-CM/PCS coding and AHA Coding Clinic
• Excellent communication and team collaboration skills
• Ability to work independently and manage multiple tasks effectively
• Familiarity with payer compliance and quality metrics
• Active involvement in quality assurance and process improvement initiatives
• Ensuring compliance with all relevant healthcare regulations and standards