Remote - Clinical Documentation Integrity Specialist

Mosaic Life Care; Central City (NE); Remote; USD 70,000 - 95,000; Full time

Benefits offered by this job

Concierge service

Employee lounge

Wellness programs

Free parking

On-site clinic

Virtual health clinic

Job summary

Mosaic Life Care is seeking a Clinical Documentation Specialist to perform basic to intermediate CDI reviews and coding updates. You will collaborate with physicians and the coding team to ensure accurate documentation that supports severity of illness and risk of mortality, and participate in quality improvement activities.

The role requires an Associate's Degree in Nursing (Bachelor's preferred) and 3 years of ICU/critical care experience, with CCDS certification within 2 years.

Qualifications

• 3 Years - Clinical experience in an ICU/Critical Care acute care setting (Required)
• CCDS certification required within 2 years or equivalent
• Ability to read and interpret medical records and encoder instructions

Responsibilities

• Perform basic to intermediate CDI reviews and re-reviews; submit queries to providers; handle first and second appeal levels.
• Assign and update ICD-10-CM/PCS codes and DRG classifications; ensure timely reviews.
• Identify documentation gaps and communicate with providers to capture accurate documentation.
• Complete second-level reviews including mortality and quality reviews.
• Participate in staff training and interdepartmental improvement activities; collaborate with the team.
• Engage in professional development via webinars and online education; maintain productivity goals.

Education

Associate's Degree - Nursing

Bachelor's Degree - Nursing

Job description

Candidates residing in the following states will be considered for remote employment: Remote work will not be permitted from any other state at this time

Works under the supervision of the Manager to complete basic to intermediate CDI reviews and re-reviews, submit queries to providers, complete first and second appeal levels. Review and ICD-10-CM/PCS codes are assigned and appropriate DRG based on Official Coding Guidelines.

Conducts basic to intermediate initial, concurrent and retrospective reviews of clinical documentation for all selected admissions to initiate the tracking process and document findings. Abstracts data from concurrent and retrospective charts, as well as computerized data systems using documentation, Official Coding Guidelines and Official Query Guidelines.

Assigns and updates ICD-10-CM/PCS codes and baseline and working MS-DRG and APR-DRG DRG for accounts, reviewing in a timely manner and documenting thoroughly in clinical documentation integrity system.

Identifies need to clarify documentation in records and initiates communication with provider utilizing the appropriate query tools in order to capture the documentation in the medical record that accurately supports the patient’s severity of illness and risk of mortality.

Completes second level review including mortality reviews and quality reviews.

Participates in staff training and departmental improvement activities and uses the results of the quality of quality audits to initiate change in practice. Collaborates with other members of the interdisciplinary team to achieve accurate documentation for coding (example: rounds with physicians, attends team conference).

Assumes responsibility for professional development by participating in educational opportunities via webinars, online education and online meetings.

Achieves CDI quality and productivity goals.

Associate's Degree - Nursing - Required

Bachelor's Degree - Nursing - Preferred

Work Experience

• 3 Years - Clinical experience in an ICU/Critical Care acute care setting - Required
• Certified Clinical Documentation Specialist (CCDS) - Required within 2 Years Or
• Input and retrieve data, speaking clearly, answering phones, precise hand\eye coordination, fine motor skills and good writing skills.
• Ability to work with interruptions, and flexibility in hours and workflow, foster teamwork and promote service and quality.
• Prolonged time spent looking at computer screen and keyboarding, sitting.
• Knowledge of care delivery documentation systems and related medical record documents.
• Read and interpret from the medical record, analyze encoder instructions, understand documentation.
• Visual, hearing.

Mosaic Life Care is a health care system in northwest Missouri. With a vision of transforming community health by being a life-care innovator, Mosaic places the holistic needs of patients first by providing the right care at the right time and place, offering high value and quality health care.

Mosaic also offers several perks with a focus on ensuring our employees feel valued, including concierge services, employee lounge, wellness programs, free covered parking, free on-site and virtual health clinics and many more.