About This Role
This remote role focuses on improving clinical documentation to ensure the accuracy, quality, and completeness of patient records at various facilities. The specialist will ensure that coded diagnoses and procedures accurately reflect the patient's clinical status and the care provided, collaborating with healthcare providers through education and a query process to support continuity of care, quality metrics, and regulatory compliance.
Responsibilities
- Analyze inpatient clinical records to identify opportunities for improving documentation accuracy, ensuring assigned codes reflect patient severity and acuity
- Adhere to corporate recommended CDI workflows and use CDI and medical records software, such as 3M 360 Encompass and Iodine Interact, to support documentation practices
- Utilize approved physician query processes to clarify documentation, ensuring queries are compliant, necessary, and non-leading, and follow up daily on unanswered queries
- Conduct follow-up reviews of patient records to identify new documentation opportunities and ensure accuracy through continuous review
- Track CDI activities within CDI software, accurately reporting impact metrics and maintaining clear records of all interactions and documentation efforts
- Provide education and training to providers, explaining recommendations for documentation improvement and offering insights through individual or group sessions
- Collaborate closely with coding professionals to ensure accurate diagnostic and procedural data through complete and compliant documentation
- Lead physician education initiatives, developing strategies to improve documentation practices at the facility level and conducting formal training sessions
- Monitor regulatory changes in coding, documentation, and quality metrics, ensuring compliance with updated standards and sharing information with staff as needed
- Create and submit accurate reports in a timely manner, maintaining up-to-date knowledge of best practices and industry standards to support CDI goals
- Perform other duties as assigned
- Maintain regular and reliable attendance
- Comply with all policies and standards
Requirements
- Associate Degree in Nursing, or comparable clinical field (e.g., International MD) required
- 3-5 years of acute care hospital nursing experience (e.g., medical/surgical unit, intensive care) required
- Strong knowledge of clinical documentation improvement principles, inpatient coding guidelines, and quality metrics
- Excellent analytical and problem-solving skills to identify opportunities for documentation improvement
- Proficiency in CDI and medical record software systems (e.g., 3M 360 Encompass, Iodine Interact)
- Effective communication and interpersonal skills to collaborate with physicians and interdisciplinary teams
