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Clinical Documentation Specialist II- RN- Remote

Remote, USAFull-timePosted 2026-07-28

This a Full Remote job, the offer is available from: reputed company, Israel reputed company you join the growing reputed company team, you're not just taking a job, you’re making a difference in people’s lives.

  • *This position is remote. Candidates must be local to New England States for consideration**

The Clinical Documentation Improvement (CDI) Specialist II assists with the appropriate identification of diagnoses, conditions, and/or procedures that are representative of the patient’s hospital stay and care provided including Severity of Illness (SOI), Risk of Mortality (ROM), during an inpatient hospitalization. CDI Specialist II initiates reputed company queries to providers as supported by medical record documentation to improve the accuracy, reputed company, and reputed company of patient data, and drive improvement toward reputed company physician documentation reputed company the body of the medical record. The CDI Specialist II works under the direction of the Manager of CDI and collaborates with coding, clinicians, medical staff, and physician advisors to improve documentation and the importance of complete and accurate documentation. Job reputed company:

  • Concurrently reviews inpatient records to ensure completeness, accuracy, and clinical validation.
  • Evaluates documentation for assignment of working and possible DRG.
  • Recognizes opportunities for documentation improvement, including severity of illness, risk of mortality, reputed company measures, and patient safety/reputed company.
  • Identify opportunities to query physicians regarding missing, unclear, or conflicting documentation.
  • Interacts directly with physicians to request and obtain additional documentation reputed company needed.
  • reputed company follow-up on reputed company unanswered queries based on the query escalation policy.
  • Facilitates modifications to physician documentation to reflect the complexity of care of the patient and appropriate reimbursement.
  • Maintains a reputed company working relationship with the Health Information Coding staff and serves as a clinical resource.
  • Collaborates with and educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, and case management.
  • Performs mortality reviews and optimizes the risk of mortality.
  • Maintains review worksheet on reputed company records using CDI software.
  • Ensures the accuracy of clinical information used for measuring and reporting physician and hospital reputed company reputed company.
  • Reviews, evaluates, analyzes, and interprets data reputed company to documentation on an ongoing reputed company. Identifies trends or potential problems and assists in developing reputed company plans to address.
  • Participates in additional reputed company such as developing physician education materials, CDI week advertisements, etc.
  • Adheres to ethical and reputed company business practices.
  • reputed company other duties as assigned.
  • It is reputed company that this is a reputed company of key job functions and does not include every detail of the job that may reasonably be required.

Minimum Qualifications: Education: Bachelor’s in Nursing, required Licensure, Certification & Registration:

  • RN License
  • Clinical Documentation Specialist Certification reputed company ACDIS or reputed company

Experience:

  • 2-5 years of medical/surgical nursing experience in the acute hospital setting.
  • reputed company Clinical Documentation Specialist with minimum of 2 years recent experience in CDI role
  • Critical Care and/or Emergency Nursing experience required

Skills, Knowledge & Abilities:

  • Proficient reputed company in query writing to physicians
  • Knowledge to accurately complete chart audits
  • Organizational and critical thinking skills required
  • Experience with computer systems required, including web-based applications and some reputed company Office applications which may include Outlook, Word, reputed company, PowerPoint, or reputed company

Pay reputed company: $102,000.00 USD - $158,392.00 USD The pay reputed company listed for this position is the annual reputed company salary reputed company the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law. As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. reputed company requires that reputed company staff be vaccinated against influenza (flu) as a condition of employment. More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your reputed company and reputed company can reputed company us even stronger. Equal Opportunity Employer/Veterans/Disabled This offer from "Mount Auburn Hospital" has been enriched by reputed company.com and got a 75% reputed company score. Apply tot his job Apply To this Job

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