Clinical Documentation Integrity Specialist

We are seeking a knowledgeable clinical documentation specialist to become part of our team that oversees Clinical Documentation Integrity Program in several client hospitals. In this role, one will be responsible for ensuring of clinical documentation and coding complies with federal laws, as well as assuring the clinical validation of coded diagnosis and procedures. Familiarity with HACs, PSI will be appreciated.

In this role one will be responsible for initial coding of diagnosis, procedures and complications that are taking place during the hospital stay. Discussing finding with physician and leadership team will be the crucial part of the job.

This position is hybrid, remote and onsite time will be available. This is a full time position with full benefits.

Applying knowledge of medical terminology and procedures to evaluate clinical documents.
Collecting medical information from healthcare providers and updating medical records.
Verifying the accuracy of patient medical information and obtaining missing information.
Monitoring diagnoses, treatments, and follow-up entries in medical records.
Interpreting and preparing clinical reports for healthcare professionals and public health officials.
Meeting with healthcare providers to explain findings and facilitate actions.
Keeping abreast of advancements in the field of clinical documentation and changes in regulations.

Clinical Documentation Integrity Specialist Requirements:

Medical Graduate, MD, MBBS or equivalents
At least 1 year of experience preferred
Candidates with no experience will be also considered
Credentials such as CDIP, CCDS, and CCS are preferred
Advance knowledge of clinical pathophysiology and anatomy is must
Proficiency working with Microsoft office tools including Excel.
Advanced knowledge of best practices in Documentation and coding preferred
In-depth knowledge of medical terminology, coding, and procedures applicable to CDI
Advancing knowledge in quality outcomes, PSI, HAC and Risk Adjustment preferred
Ability to keep informed of advancements and regulations in clinical documentation.
Excellent organizational and communication skills.

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