Clinical Documentation Improvement Specialist (Remote), Day Shift, Clinical Documentation
Core
Examine medical records to ensure documentation is accurate, complete, and reflective of the patient's clinical status; detect inconsistencies and request provider clarifications to support correct coding and compliance.
Role type
Clinical Documentation Improvement Specialist (IC)
Builds
Accurate medical records supporting ICD-10-CM/PCS and CPT coding for reimbursement and regulatory compliance
Domain
Healthcare / Clinical Documentation
Required skills
Medical record review, Provider query management, ICD-10-CM/PCS coding, CPT coding, CMS guideline compliance, Quality metrics tracking, Physician education, Audit support, Clinical indicators interpretation
Preferred skills
Lean Six Sigma Green belt, Solventum360 proficiency, Inpatient coding experience
Technologies
Solventum360, ICD-10-CM/PCS, CPT, DRGs, SOI/ROM, HCC
Responsibilities
Examine medical records for accuracy and completeness; Detect inconsistencies and request provider clarifications; Verify documentation supports correct coding; Ensure alignment with regulatory standards; Communicate with physicians to improve documentation practices; Track and report documentation quality metrics; Assist in internal and external audits; Maintain clinical documentation knowledge via continuing education.
Seniority
Mid-Senior level, hands-on IC