Remote CDI Specialist: Elevate Medical Record Documentation

Jefferson Health Plans; United States; Remote; USD 70,000 - 100,000; Full time

Job summary

Jefferson Health Plans seeks a Clinical Documentation Specialist to review medical records, identify documentation opportunities, and collaborate with physicians and coders to ensure accurate coding and compliance. This role emphasizes remote work, HIPAA compliance, and ongoing education for clinical staff.

The ideal candidate holds a BSN and health information management background, with CCDS/CDIP certification preferred. Experience in inpatient CDI and CMS requirements is highly valued.

Qualifications

• Bachelor of Science in Nursing (BSN) required.
• Bachelor of Science in Health Information Management or related field required.
• CCDS/CDIP certification preferred; CCDS within 6 months of hire.

Responsibilities

• Review medical records for complete and compliant documentation.
• Identify documentation opportunities and communicate with physicians for clarifications.
• Collaborate with coding staff to ensure discharge diagnoses and comorbidities are accurately reflected.
• Educate physicians and clinicians on coding guidelines and documentation improvements.
• Maintain HIPAA and PHI compliance in all actions.
• Document activity in CDI software tracking tools and meet productivity targets.

Skills

Medicare knowledge

CDI experience

Biomedical communications

HIPAA compliance

Remote work capability

Education

BSN

Health Information Management

Healthcare certification (CCDS/CDIP)

Tools

Epic EHR

3M DRG

MS Office

Job description

Jefferson Health Plans seeks a Clinical Documentation Specialist to review medical records, identify documentation opportunities, and collaborate with physicians and coders to ensure accurate coding and compliance. This role emphasizes remote work, HIPAA compliance, and ongoing education for clinical staff.

The ideal candidate holds a BSN and health information management background, with CCDS/CDIP certification preferred. Experience in inpatient CDI and CMS requirements is highly valued.