Remote - Clinical Documentation Integrity Specialist

Mosaic Life Care; Florida; Remote; USD 75,000 - 105,000; Full time

Benefits offered by this job

Concierge services

Employee lounge

Wellness programs

Free covered parking

On-site and virtual health clinics

Job summary

Mosaic Life Care is seeking a CDI professional to conduct basic to intermediate clinical documentation reviews for selected admissions, ensuring accurate coding and DRG assignment. You will abstract data from charts, assign codes, and query providers when documentation needs clarification to reflect severity of illness and mortality risk.

The role supports quality audits and departmental improvements, with opportunities for ongoing education and professional development.

Qualifications

• Associate's Degree in Nursing is required.
• Bachelor's Degree in Nursing is preferred.
• Certified Clinical Documentation Specialist (CCDS) within 2 years is required or equivalent.
• Knowledge of care delivery documentation systems and medical record documents.

Responsibilities

• Perform basic to intermediate CDI reviews and re-reviews for selected admissions.
• Abstract data from charts and systems per Official Coding Guidelines.
• Assigns ICD-10-CM/PCS codes and DRG based on Official Guidelines.
• Initiates queries with providers to capture documentation supporting severity of illness and risk of mortality.
• Completes second level reviews including mortality and quality reviews.
• Participate in staff training and departmental improvement activities.
• Engage in professional development through webinars and online education.

Skills

ICD-10-CM/PCS coding

Clinical documentation

Querying providers

Quality improvement

Education

Associate's Degree - Nursing - Required

Bachelor's Degree - Nursing - Preferred

Certified CCDS

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.