Role Name: Clinical Documentation Specialist
Location: Remote
Schedule: 40 hours/week 
Contract length: 3 months assignment with possible extension

Summary
This position is responsible for initiating and completing the concurrent review of medical records to ensure the information documented accurately reflects the patient’s severity of illness, clinical treatment, risk of mortality, and quality and intensity of care.
Reviews include verifying that clinical conditions are documented in diagnostic format to ensure appropriate reporting, identifying query opportunities to clarify or validate clinical conditions, assigning principal and secondary diagnoses and/or procedures for appropriate designation of DRG and LOS, and identifying quality indicators and codes that contribute to reportable quality metrics and compliance standards.

Responsibilities

• Computer, internet, and word processing experience required
• Excellent verbal and written communication skills
• Collaborative interaction and effective education skills with the medical staff and ancillary departments to collegially discuss clinical aspects of care
• Ability to perform accurate patient chart review analysis and data collection
• Ability to prioritize essential functions and multitask utilizing multiple resources and applications, including but not limited to:3M 360 , EPIC ,Outlook ,Iodine, Microsoft Teams, Zoom, SharePointAbility to demonstrate integrated knowledge of job-specific competencies
• Follow company and department policies, procedures, and directives
• Maintain HIPAA and patient confidentiality at all times
• Ability to work autonomously and productively in a remote work environment while adhering to all company security policies and remote-work agreement
• Ability to interact in a positive and constructive manner

Skills 

• Completes initial concurrent review process and subsequent reviews for all selected admissions to initiate the clinical documentation review process
• Documents findings and identifies clinical documentation clarification opportunities related to diagnosis specificity, documentation inconsistencies or conflicts, quality of care and patient safety, and resource utilization
• Identifies principal diagnosis, secondary diagnoses, and procedures to assign a concurrent working DRG based on the clinical picture
• Collaborates with medical staff, medical records coders, and CDI leadership to determine a final DRG that accurately reflects severity of illness, risk of mortality, and resource utilization
• Reconciles DRG mismatches with coders and CDI coordinators in a respectful and positive manner
• Queries medical staff to obtain accurate and complete chart documentation that supports severity of illness
• Maintains department, organizational, and industry compliance in the query process
• Meets department productivity expectations for CDI reviews, including initial reviews, secondary reviews, retrospective reviews, DRG mismatch analysis, and query follow-ups
• Meets minimum thresholds in monthly audits for quality, compliance, workflow, and outcomes
• Demonstrates strong understanding of coding guidelines and working knowledge of CMS, NCHS, and AHA guidelines and their impact on reimbursement, quality metrics, utilization management, and physician and health system statistics
• Takes responsibility for assigned projects and performs additional or miscellaneous duties within scope of knowledge and ability as requested by management

Education and Certifications

• MD, BS, or higher in a healthcare-related field, or
• Licensed coder (CCS) with a strong clinical knowledge base and background
• Required Certifications / Licensure
• Clinical licensure (RN, PA, NP, MD, or FMD) and/or Coding certification (CCS)
• Preferred Certifications : CCDS and/or CDIP

 
 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $ 55.00/hr.