Clinical Documentation Integrity Specialist
Quorum Health
full-time
Posted on:
Location Type: Remote
Location: Tennessee • United States
Visit company websiteExplore more
About the role
- Provides clinically based, concurrent and retrospective reviews of all inpatient medical records.
- Ensures documentation accurately reflects quality of care, severity of illness and risk of morality to support correct coding, reimbursement and quality initiatives.
- Proactively contacts physicians or other clinicians as needed to clarify procedures/diagnoses to ensure proper documentation.
- Performs initial case reviews and follow up reviews.
- Submits queries to providers as needed to ensure complete documentation of relevant diagnoses.
- Assigns diagnosis codes following the Official Guidelines for Coding and Reporting and AHA Coding Clinics to obtain an accurate working DRG.
- Promotes a partnership with Coding/HIM team to ensure the accuracy of principal diagnosis, procedures, and completeness of documentation to determine the working and final DRG, severity of illness and risk of mortality.
Requirements
- Bachelor's degree in a clinical or coding study is preferred.
- 2-5 years acute clinical or coding (IP) experience preferred.
- Clinical Documentation Integrity experience preferred.
- More experienced CDI Specialists will be expected to attain certification in DCI.
- Basic requirements: RN or LVN with current state license, a coding background with sound clinical expertise or a Foreign Medical Graduate.
- CCDS or CDIP preferred/ encouraged with proof of certification when applicable.
- Proficiency in Microsoft applications, EMR applications, CDI and coding software.
Benefits
- Competitive salary and benefits package.
- Opportunities for professional development and advancement.
- Supportive work environment with a collaborative team.
- Comprehensive healthcare coverage.
- Retirement savings plan.
- Paid time off and flexible scheduling options.
- Student loan repayment program.
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical documentation integritydiagnosis codingacute clinical experiencecoding experiencemedical record reviewdocumentation accuracyseverity of illness assessmentrisk of mortality assessmentDRG assignmentquery submission
Soft Skills
communicationcollaborationproactive engagementattention to detailanalytical thinking
Certifications
CCDSCDIPRN licenseLVN license