Clinical Documentation Improvement Specialist – Nationwide

Job ID: 915177
Job Location: Nationwide

Clinical Documentation Improvement Specialist


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Are you searching for exciting Clinical Documentation Improvement career opportunities? Excite Health Partners is looking for experienced Clinical Documentation Improvement Specialists to join our dynamic team.

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Excite Health Partners is not your average health information management (H.I.M.) recruiting company. We are committed to advancing patient care through talent and technology and we demonstrate this by offering clinical documentation improvement (CDI) and medical coding solutions nationwide. In addition, we are pleased to offer health information technology services. At Excite, we understand that CDI is a true collaboration between physicians, nurses, medical coding staff, and other healthcare professionals and our services reflect this. Our employees are our priority. We strive to find you the positions you desire that match your CDI background and are in line with your career goals. We are dedicated to meeting the needs of both our customers and our employees by providing unparalleled service and creating long-lasting relationships emphasizing honesty and responsiveness.

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Keep reading for more details about this position!

Job Description:

Responsibilities: Under general supervision, the Clinical Documentation Improvement Specialist is responsible for improving the overall quality and completeness of clinical documentation. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risks of mortality, and complexity of care of the patient. Exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions or procedures.

  • Follows guidelines for coding and documentation to ensure physicians and hospital compliance. Remains current with coding information to ensure accuracy of codes assigned based on documentation. Guides, supports, and sponsors concurrent clinical coding. Provides clinical interpretation of physician documentation. Acts as a liaison between the clinical and coding functions.
  • Completes initial review of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnosis, and procedures for accurate DRG assignment, risk of mortality, and severity of illness; and (b) initiate a review worksheet.
  • Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final DRG assignment upon patient discharge, as necessary.
  • Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed.
  • Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
  • Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.
  • Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
  • Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
  • Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues through daily and retrospective documentation reviews and aggregate data analysis.
  • Facilitates change processes required to capture needed documentation, such as forms redesign.
  • Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality.
  • Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, severity of illness, and/or risk of mortality.
  • Performs other job related duties as assigned.

At Excite, we value your unique background and want to be sure your experience matches the job. For the Clinical Documentation Improvement Specialist position, you should meet the following criteria:

  • Clinical Documentation Improvement Specialist/Professional
  • Must have at least three years of experience as a CDIS
  • Must have at least three years of clinical experience in an acute care hospital setting
  • Must have either the CCDS or CDIP credential, and or be an RN, NP, PA, RHIA, RHIT with prior CDI hospital based experience to be considered.
  • Individual must be proficient in ICD-10 CM & PCS, MS-DRG’s and or APR-DRG’s
  • Prior healthcare consulting experience strongly preferred
  • Strong understanding of clinical, HIM, Quality and Case Management workflow
  • Experience facilitating physician education or experience working directly and communicating with physicians
  • BS or MS degree strongly preferred
  • Remote CDI experience is preferred

Excite understands that employees are the cornerstone to our success and is proud to offer the following benefits:

  • Competitive compensation
  • Health, Vision, Dental plan
  • 401k plan with designated company match
  • Weekly pay
  • Direct deposit

At Excite, your goals are our goals. Apply today to join our team where our leaders will work with you to take your career to the next level!