United States onlyThis is a remote position.
We are seeking experienced Clinical Documentation Improvement (CDI) Specialists to support our client’s CDI program. This role is fully remote and requires expertise in EPIC electronic health records. CDI Specialists will collaborate with healthcare teams to ensure the accuracy, completeness, and specificity of clinical documentation to improve coding accuracy, quality metrics, and overall patient care outcomes.
Key Responsibilities:Review medical records to ensure complete and accurate documentation that reflects the severity of illness, risk of mortality, and proper reimbursement.
Query providers for clarification or additional documentation when necessary.
Collaborate with physicians, coders, and clinical staff to improve documentation integrity.
Utilize EPIC for chart review and data analysis.
Monitor and track documentation trends to identify improvement opportunities.
Educate physicians and clinical staff on best practices for documentation.
Ensure compliance with all applicable regulations, policies, and coding guidelines.
Review medical records to ensure complete and accurate documentation that reflects the severity of illness, risk of mortality, and proper reimbursement.
Query providers for clarification or additional documentation when necessary.
Collaborate with physicians, coders, and clinical staff to improve documentation integrity.
Utilize EPIC for chart review and data analysis.
Monitor and track documentation trends to identify improvement opportunities.
Educate physicians and clinical staff on best practices for documentation.
Ensure compliance with all applicable regulations, policies, and coding guidelines.
Requirements
Degree/Certifications: FMG (Foreign Medical Graduate), MD, or RN required.
Certifications:CDIP (Certified Documentation Improvement Practitioner) or CCDS (Certified Clinical Documentation Specialist) required.
Experience: Minimum 2 years of CDI experience required.
Technology Skills: Must be proficient in EPIC electronic medical records system.
Soft Skills: Strong analytical skills, excellent communication, and attention to detail.
Preferred Specialties: Experience in OBGYN, Pediatrics, Inpatient Psychiatry.
Preferred Skills: Quality-based reviews, mortality reviews, and risk adjustment tool experience.
AU, CA + 7 more