Lead Clinical Documentation Improvement Specialist (REMOTE)

MedStar Health; Ohio; Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare provider in Ohio is seeking a Clinical Documentation Improvement Analyst 4 to enhance medical record documentation quality. The role involves conducting audits, providing education, and ensuring compliance with various guidelines. Ideal candidates will hold a nursing degree, an active RN license, and relevant certifications, along with strong communication skills.

Qualifications

• Active RN license required.
• CCDS or CDIP certification needed.
• 6-10 years of relevant experience preferred.

Responsibilities

• Perform concurrent and retrospective reviews to enhance medical record documentation.
• Develop and deliver education related to documentation integrity.
• Participate as a subject matter expert in interdisciplinary groups.

Skills

Knowledge in medical information

Excellent communication

Team collaboration

ICD-10-CM/PCS coding proficiency

Education

Bachelors degree in nursing

Registered Nurse

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