Remote Clinical Documentation Specialist (CDI) – Acute-Care

GeBBS Healthcare Solutions, Inc.; United States; Remote; USD 55,000 - 83,000; Full time

Job summary

GeBBS Healthcare Solutions, Inc. is seeking a Clinical Documentation Specialist for a 6-month remote project. The role supports accuracy of clinical documentation in acute-care hospital settings, collaborating with physicians, nurses, coders, and CDI professionals.

The ideal candidate will have an RN or LPN background, CDI experience, and CCDS/CDIP certification, with strong knowledge of ICD-10-CM/PCS, MS-DRG, and physician query processes.

Qualifications

• Prior CDI experience in an acute-care hospital setting.
• Hands-on experience with Nuance CDE.
• CCDS or CDIP certification required.
• Knowledge of ICD-10-CM/PCS, MS-DRG methodology, CC/MCC capture.
• Strong communication and critical-thinking skills.

Responsibilities

• Perform concurrent and retrospective CDI reviews for acute-care hospital patients.
• Review medical records to identify documentation clarification needs.
• Identify opportunities for compliant physician queries based on clinical indicators and diagnoses.
• Utilize Nuance CDE to perform CDI reviews and manage physician queries.
• Collaborate with physicians, nursing staff, coders, and clinical teams to improve documentation.
• Evaluate documentation for appropriate clinical support of diagnoses and procedures.
• Support accurate assignment of MS-DRGs, CC/MCCs, and other classifications.
• Apply current CDI industry standards and hospital policies.

Skills

CDI experience

Nuance CDE

Critical thinking

Communication skills

Independent work

Education

RN/LPN background

CCDS or CDIP certification

Tools

EMR systems

CDI software

Job description

GeBBS Healthcare Solutions, Inc. is seeking a Clinical Documentation Specialist for a 6-month remote project. The role supports accuracy of clinical documentation in acute-care hospital settings, collaborating with physicians, nurses, coders, and CDI professionals.

The ideal candidate will have an RN or LPN background, CDI experience, and CCDS/CDIP certification, with strong knowledge of ICD-10-CM/PCS, MS-DRG, and physician query processes.