This is a remote position. You must self provide high speed internet access and a phone line. Depending on shortages, you may be required to self-provide additional monitors (you will need to work on a minimum of 2 monitors). This job does not require any travel.Responsible for ensuring the overall quality and completeness of medical recordDocumentation for all payor groups, all DRG’s, including MS, AP, and APR.Facilitates modifications to clinical documentation through concurrent interaction withphysicians, nursing staff, other patient caregiver and Health Information coding staff tosupport that appropriate reimbursement and clinical severity is captured for the level ofservice rendered to all inpatients.Supports timely, accurate and complete documentation of clinical information used formeasuring and reporting physician and hospital outcomesEducates all members of the patient care team on an ongoing basis, as needed.Professional team player, able to communicate well with others on all levels.Regular electronic contacts with other personnel throughout and outside the hospitalContacts may be in by telephone or through e-mail correspondence.Flexible with a working knowledge of all areas of adult medicine.Ability to sit for very long periods of time, manual dexterity and mobility for extensive use ofcomputer screen, keyboard, copy and facsimile machines, reader/printer and other officeequipment.Adequate to perform essential functions of the job with the type of judgments and potentialconsequences outlined above.Experience Required
EPIC EHR
Clintegrity CDE software
5 years minimum experience as Clinical Documentation Specialist in an acute setting, preferably Level 1 Trauma Center.
CDI Subject matter expert for ALL PAYORS, all DRG groups (MS-DRG, APR-DRG, AP-DRG)
PSI/HAC/HCC (Risk adjustment coding) knowledge/experienceEducation RequirementsRegistered Nurse, any state. BSN or higher preferredLicense/Certification Requirements
CCDS or CDIP
Registered Nurse, any state. BSN or higher preferred
Coding certification: CCS or CRC
Special RequirementsEssential mental abilities: excellent critical thinking skills, able to assess, evaluate and teach. Must be self governed, disciplined, and organized.Requires excellent work ethic, analytical thinking, problem solving, excellent computer skills, excellent verbal and written communication with knowledge of email etiquette . Must be proficient in Word, Excel, PowerPoint and typing (60 WPM)Salary Min ($)USD $40.00Salary Max ($)USD $64.00
