Clinical Document Improvement Specialist (Remote)

Shift: M-F 8 hours and weekends
Remote

Position Summary:

The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through comprehensive auditing and evaluation of the medical record. Proactively solicits clarification from physicians and other healthcare providers when further specificity is needed to ensure accurate quality data and appropriate reimbursement. Educates others on documentation guidelines on an ongoing basis. Collects and analyzes data to provide reports and make recommendations.

• Review inpatient adult medical records across UCI Health s academic medical center and community network hospitals to ensure accurate, complete, and compliant documentation.
  Validate DRGs, identify documentation gaps, and issue physician queries as needed.
• Collaborate with providers, coders, and care teams to support documentation accuracy and reimbursement.
• Ensure documentation accurately reflects severity of illness and risk of mortality.

Required Qualifications:

• Strong clinical knowledge with ability to interpret clinical documentation
• Five (5) or more years of clinical experience as either an RN or Physician and 3 years experience in CDI
• Familiarity with Utilization Review criteria
• Familiarity of Joint Commission and CMS requirements
• CDI Credential (CCDS or CDIP)
• Bachelor of Science in Nursing or Medical School Graduate