Clinical Documentation Improvement Specialist

Where compassion meets innovation and technology and our employees are family.

Thank you for your interest in joining our team! Please review the job information below.

Full-time remote Certified Coding Specialist role requiring high clinical proficiency to review complex pediatric patient records in line with payer initiatives and acute/chronic disease knowledge. Requires education in anatomy, physiology, pathophysiology, and pharmacology, along with knowledge of medical coding guidelines and regulations, including CMS and private payers.

Responsibilities include analyzing and interpreting medical documentation, formulating physician queries, benchmarking and analyzing clinical documentation program performance. Must understand ICD coding/reporting, APR-DRG assignment, severity of illness, risk of mortality, and data quality.

Acts as a resource for HIM coders and physicians, educating patient care teams on documentation standards and linking documentation to coding and DRG assignments. Collaborates with interdisciplinary teams including physicians, nurse practitioners, case management, quality, risk management, and others.

Maintains professional development through workshops and in-services. Adheres to patient confidentiality and hospital policies, timely conducts review and queries, supports documentation improvement, and assists in appeals. Uses Microsoft Office, Epic, and 3M CDI tools.

Requirements:

• RHIA, RHIT, CCS, CDIP, or CCDS certification with minimum two years hospital ICD coding experience OR clinical credentials (RN, LVN, BSN) with a minimum of three years clinical experience in Pediatrics, Med-Surg, ICU, or Surgery.
• Certification (RHIA, RHIT, CCS) required or to be attained within one year of employment; CDIP or CCDS likewise required or to be attained within one year.

The work is computer-based and primarily done remotely.

This role is vital to ensuring accurate clinical documentation and coding to support quality patient care and proper reimbursement.