Healthcare Clinical Documentation Integrity Consultant
Berkeley Research Group (BRG)
full-time
Posted on:
Location Type: Remote
Location: Remote • New York • 🇺🇸 United States
Visit company websiteSalary
💰 $70,000 - $150,000 per year
Job Level
Mid-LevelSenior
About the role
- Review inpatient medical records for identified payer populations on admission and throughout hospitalization.
- Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.
- Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality measures, and patient safety indicators (PSI).
- Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses, and ancillary staff.
- Work collaboratively with the coding staff to assure documentation of discharge diagnoses and comorbidities are a complete reflection of the patient’s clinical status and care.
- Develop and implement plans for education of physician, nursing, and ancillary staff on documentation improvement.
Requirements
- 4-7 years of experience as a Clinical Documentation Improvement (CDI) Specialist within a hospital setting or as a CDI consultant, or a combination thereof.
- RN, BSN, or Health Information Management degree required.
- Currently licensed as a Registered Nurse – ICU, OR, ED specialty preferred, with a strong understanding of clinical workflow.
- Minimum 2 years of inpatient coding experience with ICD-10 CM/PCS preferred.
- ACDIS or AHIMA certification preferred.
- Strong knowledge of CDI principles, including the ability to audit medical records, teach CDI principles to clinicians, coders, and other healthcare professionals.
- Experience in clinical documentation improvement, coding, audit, or Health Information Management.
- Ability to assist with the development of CDI and HIM training and consulting tools and methodologies.
- Excellent organizational, analytical, and writing skills, with the ability to demonstrate critical thinking and problem-solving.
- Strong verbal and written communication skills, with excellent public speaking and presentation abilities.
- Effective communication with physicians, coding professionals, and other stakeholders.
- Knowledge of regulatory guidelines and Medicare Part A, MS-DRG, and/or APR-DRG payment methodologies.
- Ability to pass a written clinical competency assessment.
- Familiarity with hospital systems such as EPIC, MEDITECH, or similar platforms is desired.
- Strong proficiency in MS Office applications, including Word, PowerPoint, Excel, and Outlook.
- Excellent time management skills and the ability to handle multiple priorities effectively.
Benefits
- Competitive sign-on bonus to welcome exceptional talent.
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical documentation improvementinpatient codingICD-10 CMICD-10 PCSauditing medical recordsteaching CDI principlesdeveloping training toolscritical thinkingproblem-solving
Soft skills
organizational skillsanalytical skillswriting skillsverbal communicationpresentation skillstime managementability to handle multiple priorities
Certifications
ACDIS certificationAHIMA certificationRegistered Nurse license