Responsible for ensuring the overall quality and completeness of medical record

     Documentation for all payor groups, all DRG’s, including MS, AP, and APR.

     Facilitates modifications to clinical documentation through concurrent interaction with

     physicians, nursing staff, other patient caregiver and Health Information coding staff to

     support that appropriate reimbursement and clinical severity is captured for the level of

     service rendered to all inpatients.

     Supports timely, accurate and complete documentation of clinical information used for

     measuring and reporting physician and hospital outcomes

     Educates all members of the patient care team on an ongoing basis, as needed.

     Professional team player, able to communicate well with others on all levels.

     Regular electronic contacts with other personnel throughout and outside the hospital

     Contacts may be in by telephone or through e-mail correspondence.

     Flexible with a working knowledge of all areas of adult medicine.

     Ability to sit for very long periods of time, manual dexterity and mobility for extensive use of

     computer screen, keyboard, copy and facsimile machines, reader/printer and other office

     equipment.

     Adequate to perform essential functions of the job with the type of judgments and potential

     consequences outlined above.

• EPIC EHR
• Clintegrity CDE software
• 5 years minimum experience as Clinical Documentation Specialist in an acute setting, preferably Level 1 Trauma Center.
• CDI Subject matter expert for ALL PAYORS, all DRG groups (MS-DRG, APR-DRG, AP-DRG)

PSI/HAC/HCC (Risk adjustment coding) knowledge/experience

Registered Nurse, any state. BSN or higher preferred

• CCDS or CDIP
• Registered Nurse, any state. BSN or higher preferred
• Coding certification: CCS or CRC

This is a remote position. You must self provide high speed internet access and a phone line. Depending on shortages, you may be required to self-provide additional monitors (you will need to work on a minimum of 2 monitors). This job does not require any travel.