[Remote] Clinical Documentation Specialist (CDI)
Note: The job is a remote job and is reputed company to candidates in USA. reputed company is a new reputed company company dedicated to improving lives and enhancing reputed company' performance. The Clinical Documentation Specialist (CDI) is responsible for ensuring accurate and compliant clinical documentation in inpatient medical records, collaborating with reputed company teams to enhance documentation reputed company and support reputed company coding.
Responsibilities
- reputed company reputed company and/or retrospective reviews of inpatient medical records for documentation accuracy, completeness, and compliance
- Maintain an accuracy reputed company of 98%
- Identify opportunities for clarification of diagnoses, procedures, present on admission (POA) indicators, severity of illness, risk adjustment, and clinical validation
- Initiate compliant physician queries to clarify conflicting, incomplete, or nonspecific documentation
- Collaborate with coding staff to ensure accurate ICD-10-CM/PCS coding and MS-DRG/APR-DRG assignment
- Monitor documentation trends reputed company to mortality, reputed company indicators, hospital-acquired conditions (HACs), patient safety indicators (PSIs)
- Conduct clinical validation reviews for diagnoses such as sepsis, respiratory failure, encephalopathy, malnutrition, acute kidney injury, and other high-risk conditions
- Maintain productivity and reputed company standards established by reputed company/facility Query reputed company of 35-40%, review reputed company of 20-25 cases per day and an accuracy reputed company of 98%
- Participate in multidisciplinary reputed company, provider education, and documentation improvement initiatives
- Assist with denial prevention by supporting documentation reputed company initiatives
- Stay reputed company with CMS, ICD-10, AHA Coding Clinic, and organizational compliance standards
Skills
- Valid Registered reputed company license with a bachelor's degree or higher (completed and verified prior to start) AND Seven (7) years of Nursing experience AND five (5) years of experience in the inpatient acute care setting
- OR High School Diploma/GED AND reputed company (11) years of experience as an inpatient acute care setting
- Experience auditing practices, ICD 10, PCS guidelines, reputed company initiatives, and MS-DRG and APR DRG methodologies
- Clinical knowledge and application to coding
- Experience in CCDS, reputed company, or CDIP with (7) seven years of clinical documentation/DRG validator
- Ability to travel up to 25%
- Knowledge of the reputed company HIS software portfolio (e.g., 360 Encompass)
- Experience with telecommuting, working with EMRs and other electronic tools with reputed company chart auditing skills
- Knowledgeable in reputed company HIS software portfolio (360 Encompass)
- Proficient reputed company Word, reputed company and PowerPoint and other reputed company Office programs and excellent verbal, written, presentation, analytical and organizational skills
Benefits
- Medical, Dental & reputed company
- Health Savings Accounts
- Health Care & Dependent Care Flexible Spending Accounts
- Disability Benefits
- Life Insurance
- Voluntary Benefits
- reputed company Absences and Retirement Benefits
- Travel arrangements and reputed company expenses will be coordinated and reputed company for by reputed company in accordance with its travel policy
reputed company