Clinical documentation integrity (cdi) specialist

job summary:
We are seeking an experienced Clinical Documentation Integrity (CDI) Specialist to perform concurrent reviews of inpatient medical records. This role focuses on ensuring that the patient's severity of illness, acuity of care, diagnoses, procedures, and treatments are accurately and completely reflected in the medical record.

location: Telecommute
job type: Contract
salary: $50 - 55 per hour
work hours: 9am to 5pm
education: Bachelors


responsibilities:
Key Responsibilities

Perform concurrent reviews of inpatient medical records for documentation accuracy and completeness.

Identify documentation opportunities related to severity of illness, acuity, diagnoses, procedures, and treatments.

Initiate compliant physician/provider queries for clarification and specificity.

Follow up on outstanding queries to support completion prior to patient discharge.

Review and update CDI/DRG information based on changes in the patient's clinical status.

Validate the principal diagnosis (PDx), DRG, and supporting clinical documentation.

Collaborate with physicians, Coding, Quality, and multidisciplinary healthcare teams.

Provide education regarding clinical documentation opportunities that impact acuity, quality, and coding.

Maintain current knowledge of CDI guidelines, practices, and compliant query standards.

Provide coverage for other CDI Specialists as needed.

Required Qualifications

Active Registered Nurse (RN) license required.

3+ years of acute-care hospital nursing experience, with critical care experience such as ED, Trauma, or ICU strongly preferred.

2+ years of Clinical Documentation Integrity (CDI) experience preferred/required.

Candidates with 5 years of acute-care nursing experience, including 3 years of critical care, may be considered in lieu of 2 years of CDI experience.

CCDS or CDIP certification preferred. Candidates who are not currently certified must be able to obtain CCDS or CDIP after meeting eligibility requirements.

Strong understanding of inpatient clinical documentation, provider queries, principal diagnosis, and DRG review.

Experience with Epic and 3M 360 preferred.

Previous experience working remotely preferred.

Strong critical-thinking, analytical, communication, and organizational skills.

qualifications:
patient/acute-care CDI experience, RN licensure, provider query experience, and demonstrated experience with concurrent chart review and DRG validation.

skills:
analytical,communication,organizational skills,critical-thinking,CCDS,CDIP,Clinical Documentation Integrity (CDI),clinical,critical care,ICU,healthcare,principal diagnosis,medical records,medical record,clinical documentation,multidisciplinary,nursing,Trauma,quality reporting,Registered Nurse (RN)

Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.

At Randstad Digital, we welcome people of all abilities and want to ensure that our hiring and interview process meets the needs of all applicants. If you require a reasonable accommodation to make your application or interview experience a great one, please contact View email address on click.appcast.io.


Pay offered to a successful candidate will be based on several factors including the candidate's education, work experience, work location, specific job duties, certifications, etc. In addition, Randstad Digital offers a comprehensive benefits package, including: medical, prescription, dental, vision, AD&D, and life insurance offerings, short-term disability, and a 401K plan (all benefits are based on eligibility).


This posting is open for thirty (30) days.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.