Clinical Documentation Improvement Specialist

To enhance clinical documentation accuracy and compliance, the full-time South Carolina Licensed Outpatient CDI Specialist will conduct concurrent reviews of medical records, collaborate with healthcare providers on documentation improvement, and ensure accurate outpatient HCC coding while working in a hybrid environment. Key Responsibilities Conduct concurrent reviews of medical records to ensure comprehensive documentation of patient severity and medical necessity Collaborate with healthcare providers to identify and address documentation gaps, ensuring compliance with coding guidelines Accurately assign ICD-10-CM and CPT codes for various outpatient encounters, maintaining a coding accuracy rate of 95% or higher Required Qualifications Active licensure as a Registered Nurse in South Carolina or a compact state Minimum of three years of clinical nursing experience or experience in CDI or coding fields Certification in coding or clinical documentation improvement (e.g., CCDS, CDIP, CPC) required within the first year of employment Experience with outpatient Hierarchical Condition Category (HCC) coding preferred Bachelor's degree in nursing from an accredited institution preferred