Remote CDI Specialist - Elevate Medical Documentation

TuftsMedicine; United States; Remote; USD 90,000 - 120,000; Full time

Job summary

TuftsMedicine is seeking a Clinical Documentation Improvement Specialist to enhance the quality and integrity of the medical record. The role focuses on concurrent reviews of inpatient records to identify documentation opportunities, ensuring accuracy for severity of illness, mortality risk, diagnoses and services.

The incumbent will work in a high-volume production setting, provide guidance on documentation guidelines, and support coding, quality reporting, and compliance processes.

Qualifications

• Associate's degree in related healthcare field.
• One year of CDI experience in an acute care setting OR one year of acute care clinical experience relevant to CDI.
• Active, unrestricted RN license in MA or an NLC state; or applicable CDI certification.

Responsibilities

• Performs initial and concurrent reviews of electronic medical records to identify documentation opportunities.
• Evaluates medical records for completeness, consistency, precision and clarity.
• Identifies query opportunities for provider clarification and issues compliant, clinically supported queries.
• Exercise professional judgment in documentation and reporting according to policies.

Skills

CDI

Education

Associate's degree in related healthcare field

RN license or equivalent CDI credentials (CCDS/CDIP/AHIMA/CCS/CIC)

Job description

TuftsMedicine is seeking a Clinical Documentation Improvement Specialist to enhance the quality and integrity of the medical record. The role focuses on concurrent reviews of inpatient records to identify documentation opportunities, ensuring accuracy for severity of illness, mortality risk, diagnoses and services.

The incumbent will work in a high-volume production setting, provide guidance on documentation guidelines, and support coding, quality reporting, and compliance processes.