Clinical Documentation Improvement Specialist
United States
Full Time
2 weeks ago
No Visa Sponsorship
Key skills
LeadershipCommunicationCritical Thinking
About this role
Role Overview
- Review and evaluate medical record documentation for completeness, accuracy, and compliance.
- Collaborate with physicians, nurses, and coding professionals to ensure appropriate clinical documentation.
- Identify opportunities for documentation improvement to support coding accuracy, reimbursement, and clinical outcomes.
- Analyze medical records to ensure documentation supports quality care and appropriate reimbursement.
- Formulate compliant, clinically sound physician queries.
Requirements
- Experience: 1-2 years of clinical documentation improvement (CDI) experience.
- Certification: Registered Nurse (RN)
- Knowledge of ICD-10-CM, MS-DRGs, coding guidelines, and compliance standards.
- Excellent communication, critical thinking, and organizational skills.
- Comfortable using MS Office, email, VPNs, virtual machines, two-factor authentication, and video conferencing tools (MS Teams, Zoom, etc.).
- Experience using 3M and Epic preferred but not required.
Benefits
- Collaborative, mission-driven team environment.
- Opportunities for continuous learning, education and professional growth.
- Leadership that values your expertise and input