Remote Clinical Documentation Specialist | CDI Expert

eBSI Export Academy; United States; Remote; USD 77,000 - 116,000; Full time

Benefits offered by this job

Free Employee parking

Medical, Prescription, Dental, and Vis

Employer retirement contribution

Tuition Reimbursement

EAP support

Job summary

Adventist HealthCare is seeking a Clinical Documentation Specialist to ensure accurate and compliant medical record documentation across inpatient settings. The role involves analyzing records for accuracy, identifying missing data, and coordinating with physicians to obtain clarifications.

You will verify ICD-10-CM/PCS and CPT coding for proper reimbursement, align with CMS guidelines, and support education on documentation best practices.

Qualifications

• MD/DO/FM G, RN, Pharmacist or PT degrees or equivalent.
• RHIA or RHIT or related clinical degree preferred or within 90 days of start.
• Minimum 5 years inpatient clinical experience.
• 2+ years in clinical documentation, coding, case management, utilization review, or acute-care experience.
• Experience with ICD-10-CM/PCS, DRGs, SOI/ROM or HCC is a plus.

Responsibilities

• Examine medical records to ensure documentation is accurate, complete and reflective of patient status.
• Detect inconsistencies or missing information and request clarifications from providers.
• Verify documentation supports correct ICD-10-CM/PCS and CPT coding for proper reimbursement.
• Ensure alignment with CMS guidelines and organizational policies.
• Communicate with physicians to share insights and educate on documentation improvements.
• Contribute to quality improvement by robust documentation related to MHACs, PPCs, PSIs, SOI/ROM and mortality.
• Track and report metrics related to documentation quality.

Skills

Clinical documentation

ICD-10-CM/PCS

CPT coding

Query management

Regulatory compliance

Education

MD/DO/FM G/RN/Pharmacist/PT

Job description

Adventist HealthCare is seeking a Clinical Documentation Specialist to ensure accurate and compliant medical record documentation across inpatient settings. The role involves analyzing records for accuracy, identifying missing data, and coordinating with physicians to obtain clarifications.

You will verify ICD-10-CM/PCS and CPT coding for proper reimbursement, align with CMS guidelines, and support education on documentation best practices.