Remote Clinical Documentation Improvement Specialist

Oxford Global Resources; United States; On-site; USD 65,000 - 95,000; Full time

Job summary

Oxford Global Resources seeks a Clinical Documentation Specialist to enhance the quality, completeness, and accuracy of medical record documentation through thorough auditing and proactive physician queries to ensure accurate quality data and appropriate reimbursement.

The role involves educating staff on documentation guidelines, collecting and analyzing data for reports, and making recommendations to improve clinical documentation practices within the health system.

Qualifications

• 3 years of CDI experience required.
• Understanding of acuity levels for patient populations.
• Familiarity with Joint Commission and CMS requirements.
• Familiarity with Utilization Review criteria.
• Excellent written and verbal communication in English.
• Strong clinical knowledge to interpret documentation.
• Experience with ICD-10 coding.

Responsibilities

• Audits and evaluates the medical record to improve quality, completeness, and accuracy of documentation.
• Solicits clarification from physicians and providers to ensure accurate reimbursement and data quality.
• Educates staff on documentation guidelines on an ongoing basis.
• Collects and analyzes data to generate reports and recommendations.

Skills

Relationship building

Influence & collaboration

Time management

Acuity knowledge

Critical thinking

Communication

JCAHO CMS knowledge

UR criteria familiarity

Customer service

ICD-10 coding

Clinical interpretation

Job description

The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation through comprehensive auditing and evaluation of the medical record. Proactively solicits clarification from physicians and other healthcare providers when further specificity is needed to ensure accurate quality data and appropriate reimbursement. Educates others on documentation guidelines on an ongoing basis. Collects and analyzes data to provide reports and make recommendations.

Required Qualifications:

3 years of CDI experience Required

• Ability to establish and maintain effective working relationships across the Health System
• Ability to influence and work collaboratively with physicians and all levels of staff
• Ability to maintain a work pace appropriate to the workload
• Complete understanding of acuity levels for specific patient populations
• Critical thinking skills to problem solve and communicate with physicians on clinical issues
• Excellent written and verbal communication skills in English
• Familiarity of Joint Commission and CMS requirements
• Familiarity with Utilization Review criteria
• Must demonstrate customer service skills appropriate to the job
• Must possess the skill, knowledge and ability essential to the successful performance of assigned duties
• Previous experience with and / or training in ICD-10 Coding
• Strong clinical knowledge with ability to interpret clinical documentation