Clinical Documentation Specialist
Houston Methodist
Consultant – Healthcare Performance Improvement, Clinical Documentation Integrity
BRG
full-time
Posted on:
Location: 🇺🇸 United States
Visit company websiteSalary
💰 $70,000 - $150,000 per year
Job Level
Mid-LevelSenior
About the role
- BRG’s Healthcare Performance Improvement practice works with healthcare providers to identify and implement measurable and sustainable financial, clinical, and operational performance improvements.
- Consultant is a mid level consulting staff position supporting Clinical Documentation Integrity (CDI) teams and facilitating transfer of CDI best practices to client teams.
- Review inpatient medical records for identified payer populations on admission and throughout hospitalization and analyze clinical information to identify documentation gaps.
- Formulate clinical documentation clarifications to improve documentation of principal diagnosis, co-morbidities, POA, quality measures, and PSIs and facilitate modifications through interaction with clinicians.
- Work collaboratively with coding staff to ensure documentation reflects patient’s clinical status and care.
- Develop and implement education plans for 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.
- Willing to travel consistently (50% - 75 %, depending on project requirements and client expectations) is required for this position.
