Document Improvement Specialist

Summary:

• Duration: 6-9 months
• Work Mode: Remote
• Full time, day shift, choose shift between 6 a.m. and 5 p.m.

Responsibilities:

• Utilize clinical/nursing knowledge to improve the quality and completeness of clinical documentation.
• Collaborate with physicians to ensure accuracy of clinical information in medical records.
• Work with Coding to support appropriate severity of illness and risk of mortality.
• Provide education to physicians and ancillary staff regarding documentation clarification.
• Collaborate with hospital departments to support efforts that justify medical necessity, admission, and continuity of patient care.

Requirements:

• Certification required: RN, CCDS
• Minimum 5 years of current CDI experience.
• Epic experience.
• 3M/Solventum encoder experience.
• Current, valid AZ RN or LPN license or valid compact RN or LPN licensure for current state of practice; or certification as RHIA/RHIT/CCS/CCS-P/CPC/CIC/COC.
• Minimum of three years of recent clinical nursing, coding, or clinical documentation experience.

Preferred Skills:

• Experience in Trauma, Burn, Peds, and NICU.
• Strong critical thinking and communication skills.
• Effective interpersonal skills to interact with providers.
• Analytical skills to interpret medical record documentation and formulate appropriate provider queries.
• Knowledge of anatomy, physiology, pathophysiology, pharmacology, AHA Coding Clinic, and AHIMA Query Practice Brief guidelines.
• Ability to benchmark and analyze clinical documentation program performance.
• Knowledge of MS and APR-DRG’s, DRG assurance, Coding, Revenue Cycle, and Midas.
• Basic computer word processing skills.
• Ability to read, write, and speak effectively in English.