Remote - Clinical Documentation Integrity Specialist

Mosaic Life Care; Minneota (MN); Remote; USD 65.000 - 90.000; Vollzeit

Benefits dieser Stelle

Concierge services

Employee lounge

Wellness programs

Free parking

On-site health clinic

Virtual health clinic

Zusammenfassung

Mosaic Life Care seeks a Clinical Documentation Integrity (CDI) Specialist to review and optimize clinical documentation across admissions. You will assign and update ICD-10-CM/PCS codes, determine DRG baselines, and query providers to ensure documentation supports severity of illness and mortality risk.

Collaboration with the care team is essential. The role requires 3 years of ICU/critical care clinical experience and CCDS certification within 2 years, with strong attention to detail and

Qualifikationen

• 3 Years - Clinical experience in an ICU/Critical Care acute care setting - Required
• Certified Clinical Documentation Specialist (CCDS) - Required within 2 Years
• Input and retrieve data, speaking clearly, answering phones, precise hand/eye coordination, fine motor skills and good writing skills.
• Knowledge of care delivery documentation systems and related medical record documents.
• Read and interpret from the medical record, analyze encoder instructions, understand documentation.

Aufgaben

• Review and update ICD-10-CM/PCS codes and baseline and working DRG for accounts.
• Assigns and updates DRG based on Official Coding Guidelines.
• Identify need to clarify documentation and query providers to capture documentation supporting severity of illness and risk of mortality.
• Complete second level reviews including mortality and quality reviews.
• Collaborate with interdisciplinary team to achieve accurate documentation for coding.

Kenntnisse

ICU/CCU experience

CCDS certification

Documentation interpretation

Ausbildung

Associate's Degree - Nursing

Bachelor's Degree - Nursing

Jobbeschreibung

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.