Come grow with us in your dream job! Medrina has been voted one of the fastest growing companies and 92% of our employees feel we are the Best Place To Work! This is a remote role supporting our national teams together with CDI Director. Candidates need to reside and operate in the central or eastern time zones. This is a full-time remote role offering $75,000 - $80,000 salary with a robust benefits package including: 15 days of vacation, 7 paid holidays and 5 sick days annually, health/dental/vision plans start first day of work, employer paid life insurance, as well as a 401(k) plan with a company match after 6 months of service and more.
The Clinical Documentation Integrity Specialist (CDIS) is responsible for competency in coordinating and performing day to day operations, providing concurrent and/or retrospective review, improving documentation within all settings, and ensure complete and accurate diagnostic and procedural coded data. Communicate with appropriate healthcare team members to promote accurate and complete documentation of diagnoses and/or procedures in the health record that have direct bearing on SOI. Demonstrate an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record, as well as the ability to impart this knowledge to providers and other members of the healthcare team. Gather and analyze information pertinent to documentation findings and outcomes and use this information to develop action plans for process improvements. Promote CDI efforts throughout the organization and work in a collaborative environment.
Essential Duties and Responsibilities:
• Review and analyze patient medical records to ensure accurate and complete documentation.
• Collaborate with physicians, nurses, and other healthcare providers to clarify documentation and ensure it accurately reflects the patient's clinical status.
• Educate healthcare providers on documentation best practices and regulatory requirements.
• Conduct regular audits of medical records to identify areas for improvement and ensure compliance with coding and documentation standards.
• Gather and analyze information pertinent to documentation findings and outcomes.
• Assist in the development and implementation of documentation improvement initiatives.
• Provide or coordinate education related to compliance, coding, and clinical documentation issues within the healthcare entity.
• Develop provider education strategies to promote complete and accurate clinical documentation and correct negative trends.
• Identify patterns, trends, variances, and opportunities to improve documentation review processes.
• Identify opportunities to impact risk adjustment factors through documentation of complicating and comorbid, or major complicating and comorbid conditions
• Conduct independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics.
• Maintain up-to-date knowledge of coding and documentation guidelines, including ICD-10, CPT, and HCPCS.
• Comply with HIPAA and code of conduct policies.
• Promote and be involved locally, regionally, or nationally with professional development of the CDIS role.
• Contribute to a positive working environment and perform other duties as assigned or directed to enhance the overall efforts of the organization.
• Participate in CDI-related continuing education activities to maintain certifications and licensures.
• Provide feedback and training to healthcare providers on documentation improvement opportunities.
• Participate in multidisciplinary team meetings to discuss documentation issues and provide recommendations for improvement.
• Must follow internal policies and procedures that are consistent with official coding rules and guidelines as well as regulatory reimbursement policies issued by CMS and other payers.
• Valuing high quality standards as evidenced by reliability, consistency, accuracy, integrity, and validity in CDI practice and process.
• Respecting the confidentiality of identifiable health information and protected health information.
Education and Skill Requirements:
1. Bachelor's degree required. A degree in health information management, medical, nursing, or a related field preferred but not required. Experience required in lieu of a medical/nursing degree.
2. Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) certification required.
3. Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) required. In-depth knowledge of medical coding, billing practices, and healthcare regulations. In-depth understanding of ICD, CPT, HCPCS, DRG revenue codes, NDC’s and other guidelines and general understanding of investigative processes within a healthcare environment are required.
4. Minimum of 3 years of experience in clinical documentation improvement, coding, and communicating with medical providers such as Physicians, Nurse Practitioners and Physician Assistants required.
5. Knowledgeable about Core Measures and Patient Safety Indicators.
6. Extensive proficiency with medical terminology, anatomy, and physiology.
7. Proficiency in computer use, including database and spreadsheet analysis, presentation programs, word processing, and Internet search.
8. Proficiency in using electronic health record (EHR) systems and coding software.
Physical Requirements:
1. Remote work environment, requiring reliable, fast internet and telephone service.
2. Occasional onsite visits to clinical settings as required.
3. Ability to sit, stand, and walk for extended periods.
4. Ability to lift and move up to 25 pounds.
EOE/M/F/Vet/Disability
We are an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, pregnancy, age, national origin, disability status, genetic information, protected veteran status, or any other characteristic protected by law.
