Clinical Documentation Improvement Specialist RN
3 days ago – Be among the first 25 applicants
Overview
Position is 100% remote. Must live in Ohio.
Schedule: Monday‑Friday (8am‑5pm), 40 hrs. week.
Must be an RN for at least 10 years, with 5 years in pediatrics. ICU and/or surgery experience preferred.
Job Description Summary : Reviews inpatient medical records and identifies opportunities that will clarify patient severity of illness, risk of mortality, quality indicator measures, and intensity of care rendered. Collaborates with providers and HIM coding staff to ensure accurate clinical documentation and support diagnosis and clinical indicators in the medical record.
Essential Functions
Reviews clinical documentation to ensure accuracy and completeness.
Collaborates with healthcare providers to clarify documentation and ensure appropriate coding.
Educates healthcare providers on documentation best practices and coding guidelines.
Analyzes data and identifies trends to improve documentation and coding processes.
Develops and implements policies and procedures related to clinical documentation improvement.
Maintains up-to-date knowledge of regulatory requirements and industry standards related to clinical documentation and coding.
Education Requirement
Bachelor’s Degree in Nursing or MBBS designation, required.
Licensure Requirement
Current RN license in the state of Ohio, required.
Certifications
Certification in a health‑related field or Clinical Documentation Improvement (RHIA, RHIT, CDIP), preferred.
CDIP credential, preferred.
Skills
Critical reasoning skills in clinical decision‑making, problem solving, and ability to interpret medical record data.
Flexible, positive and clear interpersonal and communication skills with the ability to provide information in a collaborative manner with physicians and other staff.
Knowledge of computer‑based applications including but not limited to Word, Excel, 3M encoder, EHR (Epic).
Organizational skills.
Excellent written communication skills.
Experience
Five years of experience in inpatient medical/surgical or critical care setting, required.
Ten years of experience in a pediatric inpatient medical/surgical or critical care setting, preferred.
Two years of experience as a CDI Specialist, preferred.
HIM Coding experience, preferred.
Competency in ICD‑10 documentation requirements, preferred.