Clinical Documentation Improvement Specialist

🕒 August 14

🇺🇸 United States – Remote

💵 $48.1k - $81.2k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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R1 RCM

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 2017

💼 Consulting

📦 Logistics

🏥 Healthcare

💰 Private Equity Round on 2024-07

Consulting • Logistics • Healthcare

R1 RCM is a leading provider of revenue cycle management solutions for the healthcare industry. With an emphasis on maximizing financial performance and optimizing patient care, R1 offers a comprehensive platform that integrates data analytics, intelligent technologies, and deep expertise in revenue cycle management. The company assists healthcare providers—ranging from hospitals and health systems to physician and specialty care practices—in capturing revenue opportunities, improving payer and patient cash flows, and ensuring compliance with government regulations. R1 is committed to driving cost reductions and revenue improvements while enhancing the patient experience. Their suite of services includes revenue recovery, clinical integrity, and regulatory navigation, making them a trusted partner for many top healthcare providers.

📋 Description

• Conduct clinically based concurrent and retrospective reviews of inpatient medical records • Evaluate clinical-service documentation and identify opportunities to improve medical record quality • Conduct mortality reviews, PSI reviews, and other CDI leadership-focused projects • Facilitate physician documentation for conditions and procedures supporting severity of illness, expected mortality risk, and care complexity • Initiate physician interaction through queries and rounding participation when records contain ambiguous, missing, or conflicting information • Educate physicians and staff on documentation requirements, coding guidelines, and reimbursement policies • Assign working DRGs and review records throughout hospitalization for highest coding specificity • Collaborate with coders, auditors, quality improvement teams, and other stakeholders to resolve documentation issues • Stay current on clinical documentation standards, coding rules, regulatory requirements, CMS changes, and Coding Clinic Guidelines • Participate in documentation improvement initiatives and formal or informal education plans • Assist with onboarding and training new CDI team members

🎯 Requirements

• Associate’s Degree in Nursing required; Bachelor’s Degree in Nursing preferred • Three to five years of recent clinical work experience in medical-surgical, ICU, telemetry, and/or emergency department settings • Active US RN license required • Knowledge or experience with electronic medical record (EMR) platforms and CDI platforms • Highly skilled in CDI practices, coding, and documentation requirements related to quality outcomes, medical-record accuracy, and reimbursement • Current knowledge of CMS rules and regulations • Ability to learn electronic calendar, MS Teams, MS SharePoint, OneDrive, CDE One, and other CDI applications • Effective interpersonal skills • Ability to take initiative, work independently, and remain self-directed and motivated • Ability to resolve moderate- to high-complexity issues • Basic computer skills including Word, Excel, PowerPoint, and Outlook/email • Ability to give and receive positive and constructive feedback • Excellent judgment, critical thinking, and independent decision-making • Familiarity with hospital coding code sets, policies and procedures, federal and state coding reimbursement guidelines, and Coding Clinic Guidelines

🏖️ Benefits

• Annual bonus plan at a target of 5.00% • Competitive benefits package • Opportunities to constantly learn, collaborate across groups, and explore new career paths • Workplace support and reasonable accommodation for applicants with disabilities