Remote - Clinical Documentation Integrity Specialist

Mosaic Life Care; Lorida (FL); Remote; USD 70,000 - 90,000; Full time

Benefits offered by this job

Concierge services

Employee lounge

Wellness programs

Free covered parking

On-site health clinics

Virtual health clinics

Job summary

Mosaic Life Care is seeking a Clinical Documentation Improvement Specialist to review and optimize coding and documentation for hospital admissions. The role emphasizes accurate ICD-10-CM/PCS coding, DRG assignment, and provider queries to support patient severity and mortality risk assessments.

The position requires ICU/CCU experience, a nursing degree, and CCDS timing or equivalent certification, with opportunities for professional development and teamwork within an integrated care setting.

Qualifications

• 3 Years - Clinical experience in an ICU/Critical Care acute care setting - Required
• CCD(S) certificate required within 2 years or CCDS eligibility
• Ability to input and retrieve data, communicate clearly, and write accurately

Responsibilities

• Performs basic to intermediate CDI reviews on admissions and adjustments
• Assigns ICD-10-CM/PCS codes and DRG baselines for accounts
• Clarifies documentation with providers via queries
• Completes second-level and mortality reviews as needed
• Participates in staff training and quality improvement initiatives

Skills

Clinical documentation integrity

ICD-10-CM/PCS coding

DRG assignment

Query communication with providers

Interdisciplinary teamwork

Education

Associate's Degree - Nursing

Bachelor's Degree - Nursing

Tools

Clinical documentation integrity system

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.