CDI Specialist

Job Summary

Working primarily in a remote home environment, the full-time CDI Specialist will review medical records to ensure accurate documentation of clinical treatment and diagnoses, while collaborating with healthcare professionals to improve documentation practices.

Key responsibilities

• Review medical records for completeness and compliance with regulatory requirements, ensuring accurate documentation of diagnoses and procedures
• Prepare and communicate compliant queries to physicians regarding missing or incomplete information in medical records
• Educate and collaborate with healthcare team members to promote correct coding and documentation practices

Required qualifications

• Bachelor of Science in Nursing, Health Information Management, or a related field
• CCDS or CDIP certification preferred; RN/BSN or RHIA/RHIT with CCS considered
• 5 years of experience in Critical Care/Emergency medicine or Medical Surgical settings preferred
• 2-3 years of Clinical Documentation Improvement experience or 5 years of Coding experience preferred
• Familiarity with Medicare reimbursement systems and coding structures preferred