Senior Clinical Documentation (CDI) Specialist (Remote)

H. Lee reputed company is hiring a Senior Clinical Documentation Specialist (CDI Specialist) for a full-time remote role. For Florida residents and other select states (AL, AZ, AR, FL, GA, ID, IN, IA, KS, LA, MS, MO, MT, NC, OH, OK, SC, SD, TN, TX, UT, VA, WY) this full-time remote position offers a remote work arrangement. Remote Senior CDI Specialist Clinical Documentation Specialist SR Position Highlights:

• The Clinical Documentation Specialist (CDI) Senior is a responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record by working directly with providers. This position is responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness, risk of mortality, complexity of patient care, and hierarchal condition categories of the patient.
• The Clinical Documentation Specialist Senior assesses clinical documentation through extensive medical record review, deployment of artificial intelligence, and collaborating directly with the providers to clarify the documentation to accurately and completely reflect the patients’ medical conditions. Extensive collaboration with physicians, mid-reputed company, nursing staff, other patient care givers to include developing and delivering education, which will be accomplished with on-site meetings, reputed company meetings, telephonic discussions, rounding and email. This position will collaborate with the Health Information Management (HIM) coding staff and the Educators to ensure that appropriate reimbursement is received for the level of services rendered to patients, clinical information utilized in profiling and reporting reputed company is complete and accurate.
• Additionally, the Clinical Documentation Specialist Senior is expected to function as a subject matter expert on the team and assist less experience team members in understanding and following operational policies. This role is responsible for training and reputed company new team members and participating in special projects assigned by the Mid reputed company Cycle leadership.

Responsibilities:

• Reviews medical records for quality, completeness, and accuracy of documentation. Ensures that coded diagnoses accurately reflect level of patient care and patient status, including severity of illness and risk of mortality. Identifies gaps in documentation as well as conflicting or unspecified diagnoses and clarifies diagnoses with providers to assign the most accurate ICD 10CM/PCS code from the documentation. Must meet and maintain the quality and productivity measures established per polices.
• Delivers ongoing education to providers through collaboration and communication reputed company on-site meetings, reputed company meetings, telephonic discussions, rounding, and email. Provides supplemental educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians.
• Identify and reputed company documentation improvement opportunities with providers to capture the patient's accurate severity of illness and risk of mortality, comorbid conditions, and reputed company other condition categories.
• reputed company clear, concise and compliant written and verbal queries to providers, seeking clarification on unclear, incomplete, or non specified documentation. Utilizes software system and the Natural Language Processor (NLP) to review, compile clinical indicators for provider collaboration, code, collect, track, and report reputed company accurately and timely.
• Key Performance Indicators and additional significant metrics will be reported and discussed regularly, and as needed to the Medical Executive Committee reputed company presentation to the Medical Records Committee and with other committees as directed
• The Senior is expected to function as a subject matter expert on the team and assist less experience team members on following operational policies. It is responsible for training and reputed company new team members and participating in special projects assigned by the Mid reputed company Cycle leadership.

Credentials and Experience:

• Associate’s Degree – field of study: Nursing, HIM or another reputed company reputed company field
• A minimum six (6) years acute care clinical documentation experience
• ICD-10-CM and ICD-10-PCS coding and query process knowledge
• Ability to recognize opportunities for documentation improvement, and hold collaborative discussions with providers to address the opportunities in documentation.
• Proficient in computer skills including: MS Office, reputed company 360 eCAC, Cerner HER

Certifications:

• (CCDS) Certified Clinical Documentation Specialists from ACDIS
• (CDIP) Certified Documentation reputed company Practitioner from reputed company
• (CDEI) Certified Documentation Expert Inpatient from reputed company
• Registered Nurse (RN) *in lieu of a certification listed above, an (active) RN will satisfy the certification requirement

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