Clinical Documentation Improvement Specialist

The CDI Specialist is responsible for providing expert Clinical Documentation Improvement services to assigned clients. This role involves conducting comprehensive reviews of clinical documentation, collaborating with healthcare providers, and ensuring compliance with applicable standards and regulations. The CDI Specialist will also provide education and training to healthcare staff to promote accurate and complete clinical documentation.  This is a PRN fully remote position.

Essential Job duties and Responsibilities:

·        Conduct detailed reviews of clinical documentation to ensure accuracy, completeness, and compliance.

·        Identify opportunities for documentation improvement and communicate these to healthcare providers.

·        Ensure documentation practices comply with federal, state, and organizational regulations and standards.

·        Stay current with changes in clinical documentation regulations, guidelines, and industry best practices.

·        Provide education and training to physicians, nurses, and other healthcare staff on best practices for clinical documentation.

·        Collaborate with healthcare providers, coding staff, and other stakeholders to facilitate accurate and complete documentation.

·        Analyze clinical documentation data to identify trends, areas for improvement, and track the progress of CDI initiatives.

·        Prepare and present detailed reports on documentation performance, highlighting successes and areas needing attention.

Requirements:

·        CCDS, CDIP, RHIA, RHIT or other relevant credential from AAPC and/or AHIMA 

·        A minimum of 3 years’ CDI experience; within a client facing role preferred 

·        Maintain confidentiality and remain compliant by effectively handling protected health information (PHI) 

·        Exceptional oral and written communication skills with the ability to communicate effectively with physicians and other clinical disciplines 

·        Energetic, confident, self-starter with the ability to work independently and thrive in the dynamic environment of a growing company 

·        Detail oriented, with strong time management and planning skills to effectively meet deadlines 

·        Proficient in Microsoft Office, including Excel 

·        Strong technological skills with the ability to quickly and efficiently learn new systems, potentially working in more than one system at the same time