Health and Information Management/Clinical Document Improvement Specialist

Clinical Documentation Improvement Specialist

Work Mode: Remote

Duration: 6-9 months

Full-time, day shift, flexible hours between 6 a.m. and 5 p.m.

Responsibilities:

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.

Requirements:

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.

Preferred Skills:

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.