Remote CDI Specialist — Clinical Documentation Expert

Visa Hunt; United States; On-site; USD 78,000 - 96,000; Full time

Job summary

Rochester Regional Health is seeking a Clinical Documentation Specialist to join the Clinical Documentation Improvement department remotely. The role focuses on accurate documentation of severity of illness, ROM, complexity of care, and quality through chart review and collaboration with the care team.

Responsibilities include reviewing records for SOI/ROM, identifying gaps, requesting clarifications, educating the team, and inputting data into CDS software.

Qualifications

• RN license required; other clinicians may be considered.
• Active unrestricted RN candidates with at least 5 years of adult acute care in med/surg, critical care, ER, or PACU.
• If no certification, must complete CCDS or CDIP certification exam after two years of CDS hours; must pass within 6 months of eligibility.

Responsibilities

• Reviews medical record for completeness and accuracy for SOI, ROM, complexity of care, and quality.
• Accurate and timely record review.
• Recognize opportunities for documentation improvement.
• Formulate clinically credible documentation clarifications.
• Request documentation clarifications for SOI, ROM, Complexity of Care, Core Measures, and Patient Safety.
• Effective and appropriate communication with physicians.
• Provides education to the care team regarding the CDS process.
• Timely follow up on cases and resolution of those with clarifications.
• Actively participate in Team Meetings.
• Manage multiple priorities.
• Communicates with HIM staff and resolves discrepancies.
• Accurate input of data into department software.

Skills

Communication

Clinical documentation

Team collaboration

Multitasking

Education

Registered Nursing Degree

CCDS certification

Tools

Epic EMR

Nuance CDE One

Job description

Rochester Regional Health is seeking a Clinical Documentation Specialist to join the Clinical Documentation Improvement department remotely. The role focuses on accurate documentation of severity of illness, ROM, complexity of care, and quality through chart review and collaboration with the care team.

Responsibilities include reviewing records for SOI/ROM, identifying gaps, requesting clarifications, educating the team, and inputting data into CDS software.