North Carolina Licensed CDI Specialist

Job Summary

To enhance the quality of clinical documentation, the part-time North Carolina Licensed CDI Specialist will conduct pre-visit and retrospective reviews of ambulatory medical records, ensuring compliance with CMS coding guidelines while collaborating with healthcare providers remotely.

Key responsibilities

• Perform medical record reviews to ensure accurate documentation supporting Hierarchical Condition Categories and ICD-10-CM compliance
• Provide education to healthcare providers on documentation requirements and coding guidelines to improve clinical documentation accuracy
• Collaborate with various departments to address documentation concerns and identify opportunities for improvement

Required qualifications

• BSN, PA, NP, or Doctorate in a medically related field required
• Minimum of 3 years of relevant experience, preferably in ambulatory nursing or clinical settings
• Current licensure as an RN, NP, PA, or in the specific medical field associated with a Doctorate degree required
• Current Certification in Clinical Documentation Improvement (CDIP, CCDS, CCDS-O, or CDEO) highly preferred
• Experience with Medicare risk adjustment and coding/billing preferred