The posting
Join our dynamic team and make a meaningful impact in the healthcare industry. Enjoy competitive benefits upon hire, ongoing professional development, and the satisfaction of helping others every day. Take the next step in your career with Med-Metrix! Experience these exceptional benefits when you join Med-Metrix!
Fulltime Permanent Remote Fixed Weekends Off Day 1 HMO with 2 of your dependents covered for FREE Medical Cash Allowance Rice Allowance Clothing Allowance Free Lunch Daily Paid Time Off Training and Staff Development Employee Engagement Activities Opportunities for Internal Mobility
Job Purpose The Clinical Documentation Integrity Specialist focuses on the accuracy, completeness and consistency of inpatient clinical documentation to support coding and reporting of high-quality healthcare data. The Clinical Documentation Integrity Specialist performs concurrent chart reviews to validate that the clinical documentation in the medical record appropriately describes the patient’s severity of illness, complexity of care, and risk of mortality to facilitate appropriate coding. The Clinical Documentation Integrity Specialist utilizes advanced knowledge of disease processes, medications, and has critical thinking to analyze current documentation to identify gaps in clinical documentation. Duties & Responsibilities
Analyze medical records to identify incomplete, inconsistent, or inaccurate documentation related to diagnoses, treatments, procedures, severity of illness, and risk of mortality Perform concurrent chart reviews to ensure clinical documentation accurately reflects the patient’s condition, complexity of care, and services rendered to support appropriate coding and reimbursement Facilitate clarification and modification of clinical documentation through concurrent interaction with physicians and members of the healthcare team to ensure accurate representation of patient severity and DRG assignment Periodically analyze coding and documentation data to identify trends, variations, and opportunities for documentation improvement, and communicate findings to management Utilize data analytics, DRG reports, and tracking tools to monitor documentation performance, identify gaps, and support performance improvement initiatives Collaborate with physicians, nurses, coders, and other healthcare professionals to clarify documentation and obtain additional information necessary for accurate and compliant coding Provide support to coding teams by ensuring documentation supports code assignment and complies with coding guidelines and regulatory requirements Communicate effectively with coding staff and healthcare providers to resolve coding-related issues and promote documentation accuracy and consistency Conduct training and educational sessions for providers and staff on documentation best practices, coding guidelines, compliance requirements, and quality initiatives, as requested by CDI leadership Demonstrate knowledge of quality measure initiatives, including Value-Based Purchasing, Pay-for-Performance, readmission reduction programs, and related regulatory requirements Ensure clinical documentation aligns with organizational policies, coding standards, regulatory requirements, and payer guidelines Conduct routine audits and reviews of clinical documentation to evaluate quality, accuracy, and compliance, and identify opportunities for improvement Participate in quality improvement initiatives focused on enhancing clinical documentation integrity, coding accuracy, and operational performance Other duties as assigned Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
Understand and comply with Information Security and HIPAA policies and procedures at all times Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties
Qualifications
Minimum of 3 years of experience in clinical documentation improvement role preferred Minimum of 3 years nursing experience in adult acute care in med/surg, critical care, emergency, or PACU required Active RN, MD, DO, NP, or PA license required Coding credential (CCS, CPC, CCS-P) is a plus Current state Registered Nurse license highly preferred Clinic fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems Proficient in CDI tools such as encoder or CDI workflow and reporting tool Proficiency in Microsoft Office Suite Strong interpersonal skills, ability to communicate well at all levels of the organization Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses High level of integrity and dependability with a strong sense of urgency and results oriented Excellent written and verbal communication skills required
Working Conditions
Work Setup: Fulltime Permanent Remote Work Schedule: Night Shift Must possess a smart-phone or electronic device capable of downloading applications, for multifactor authentication and security purposes Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress Work Environment: The noise level in the work environment is usually minimal
Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.
