Clinical Documentation Specialist - Inpatient

Remote CDI Specialist Pride Health is hiring a CDI SPECIALIST I for a client based in Minnesota. This is a 12-month contract with competitive pay and benefits. This Position is 100% Remote and can be worked from anywhere within the U.S, but Candidates must have access to their laptop, 2 monitors, keyboard, and mouse. Equipment will not be provided. Location – Fully Remote (Rochester, MN) Pay range - $58 - $63 per hour. Length of assignment – 12-month contract. Shift – M-F, business hours (typically 8-5 EST). Job Summary Inpatient CDI reviews with productivity expectations, reconciliation with Coding, MS-DRG assignment, risk-adjustment documentation (CMS, HCC, Vizient, etc.). CCDS OR CDIP required AND a RHIT, RHIA, RN, CCS, CCS-P, or Medical Degree. Minimum of 2 years as an Inpatient CDI Specialist (the past 12 months need to be in a production role). Job Duties • The Inpatient Clinical Documentation Integrity (ICDI) Specialist is accountable for reviewing patient medical records in the inpatient and outpatient settings to capture an accurate representation of the severity of illness and facilitate proper coding. • Validates coding reflects the medical necessity of services and facilitates appropriate coding, which provides an accurate reflection and reporting of the severity of the patient's illness, along with the expected risk of mortality and complexity of care. • Documentation of discharge diagnoses and co-morbidities is a complete reflection of the patient's clinical status and care. • Utilizes advanced knowledge of disease processes (pathophysiology) and medications, and has critical thinking skills to analyze current documentation to identify gaps. Identifies opportunities in concurrent and retrospective inpatient clinical medical documentation to support quality and effective coding. • Understands and applies regulatory compliance related to documentation, coding, and billing for all health insurance plans. • Facilitates appropriate modifications to documentation through extensive interactions and collaboration with physicians, coding, case management, nursing, and other caregivers. • Serves as an effective change agent as an educator and resource for physicians and allied health staff to improve the quality and completeness of clinical documentation. • Performs all duties and responsibilities in accordance with ethical and legal business procedures, compliant with federal and state statutes and regulations, official coding rules, guidelines, and accepted standards of coding practice, including appropriate clinical documentation policies. Education: • High School diploma or GED required. • Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Registered Nurse (RN), Registered Respiratory Therapist, Certified Coding Specialist (CCS), Certified Coding Specialist-Physician-based (CCS-P), or an International or Domestic Medical Degree is also required. • License or Certification: Certified Documentation Improvement Practitioner (CDIP) certification or Certified Clinical Documentation Specialist (CCDS) certification required. Skills and Experience: • Two years of experience in an Inpatient Clinical Documentation Integrity Specialist (ICDIS) role, concurrent review of medical records in the field of ICDI, and experience in a production role within the last 12 months. • Must have strong risk adjustment coding experience. • Demonstrated skills in analytical thinking and problem-solving. • Effective verbal and written communication, including the ability to present ideas and concepts effectively to physicians, management, and other members of our healthcare team. • Self-motivated and able to work independently without close supervision. • Demonstrated ability to work well with others in a creative and challenging work environment. • Must be able to work flexible hours, which may include evenings and weekends as required to meet business needs. Pride-Health offers eligible employee’s comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, auto, home insurance, pet insurance and employee discounts with preferred vendors. Equal Employment Opportunity Pride-Health is an equal opportunity employer. We do not discriminate on the basis of the race, religious creed, color, national origin, ancestry, physical disability, mental disability, reproductive health decision making, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, veteran or military status, or any other characteristic protected by applicable federal, state, or local law. Fair Chance Employment Pride-Health is a Fair Chance employer. We consider all qualified applicants, including those with criminal histories, in a manner consistent with applicable state and local Fair Chance laws and ordinances, including, the California Fair Chance Act and all applicable local Fair Chance ordinances. Accommodations We are committed to providing reasonable accommodations to applicants and employees with disabilities. If you require a reasonable accommodation to participate in the application or interview process, or to perform the essential functions of this role, please contact us. Only applicable for San Francisco Candidates: Under the San Francisco Lactation in the Workplace Ordinance, we will provide written notice of lactation accommodation rights, and this notice will automatically be given upon hiring, any inquiry of parental leave or lactation accommodation.