• Demonstrate extensive knowledge of clinical documentation requirements and coding guidelines applicable to inpatient care and outpatient care settings.
• Review inpatient medical records for identified payer populations on admission and throughout hospitalization.
• Provide input for complete and accurate client deliverables and make valuable contributions as a team member to expert reports.
• Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.
• Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality measures, and patient safety indicators (PSI).
• Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses, and ancillary staff.
• Work collaboratively with the coding staff to assure documentation of discharge diagnoses and comorbidities are a complete reflection of the patient's clinical status and care.
• Develop and implement plans for education of physician, nursing, and ancillary staff on documentation improvement.
• Provide Interim CDS support per client need.

• A Bachelor's degree in a related discipline is required, preferably RN, BSN, or Health Information Management.
• A minimum of 4 years of experience as a Clinical Documentation Improvement Specialist (CDI) Specialist within a hospital setting, or as a CDI consultant, or a combination thereof, is required.
• Minimum 2 years of inpatient coding experience with ICD-10 CM/PCS preferred.
• CCDS, CCS, or CDIP Certification is required; RHIA, RHIT, CRC, or CPC certification is highly preferred.
• Possesses knowledge of DRG coding guidelines.
• Possess thorough understanding of the legal and compliance issues as they pertain to clinical documentation and coding.
• Prior experience and proficiency in Electronic Record systems such as Epic, Meditech, Cerner, 3M 360, or similar platforms.
• Proficiency in understanding and delivering education in All Patient Refined Diagnosis Related Group (APR DRG's).
• Experience in the delivery of CDI Education to clients regarding appropriate diagnoses for capturing accurate Severity of illness, Hierarchical Condition Category (HCC's) and Medicare Severity Diagnosis Related Group (MS DRG's)
• Prior experience in the review and analysis of health records to identify relevant diagnoses and procedures for distinct patient encounters.
• Ability to assist with the development of CDI and HIM training and consulting tools and methodologies.
• Excellent organizational, analytical, and writing skills, with the ability to demonstrate critical thinking and problem-solving.
• Strong verbal and written communication skills, with excellent public speaking and presentation abilities.
• Knowledge of regulatory guidelines and Medicare Part A, MS-DRG, and/or APR-DRG payment methodologies.
• Strong proficiency in MS Office applications, including Word, PowerPoint, Excel, and Outlook.
• Excellent time management skills and the ability to handle multiple priorities effectively.

We're excited to offer a competitive signon bonus to welcome exceptional talent.

Candidate must be able to submit verification of his/her legal right to work in the U.S., without company sponsorship.