Health and Information Management/Clinical Document Improvement Specialist

Job Description

Job Description

Summary:

• Work Mode: Remote
• Duration: 6-9 months
• Full-time, day shift, flexible hours between 6 a.m. and 5 p.m.

• Utilize clinical/nursing knowledge to improve the quality and completeness of clinical documentation of patient records.
• Collaborate with physicians to ensure clinical information in medical records is accurate.
• Work with Coding to support the appropriate severity of illness and risk of mortality.
• Provide education to physicians and ancillary staff regarding documentation clarification.
• Collaborate with hospital departments to support efforts that justify medical necessity, admission, and continuity of patient care.

• Current, valid AZ RN or LPN license or valid compact RN or LPN licensure for the current state of practice; or certification as RHIA/RHIT/CCS/CCS-P/CPC/CIC/COC.
• Minimum of 5 years of current CDI experience.
• Experience with Epic and 3M/Solventum encoder.
• Associate’s degree in Nursing or Health Information Technology or related field, or equivalent combination of training and experience.

• Certified Clinical Documentation Specialist (CCDS) certification.
• Experience in Trauma, Burn, Peds, and NICU.
• Critical care nursing background.
• Knowledge of APR DRG, mortalities, HACs/PSIs.
• Strong knowledge base in anatomy and physiology, pathophysiology, and pharmacology.
• Familiarity with AHA Coding Clinic and AHIMA Query Practice Brief guidelines.
• Basic computer skills for navigating electronic medical records.