Clinical Document Integrity Specialist

🔥 12 hours ago

🐊 Florida – Remote

🐊 Florida – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

✨ Clinical Specialist

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HCCS - Healthcare Coding & Consulting Services

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2006

🤝 B2B

📋 Compliance

B2B • Compliance

HCCS - Healthcare Coding & Consulting Services is a US-based provider of remote medical coding, documentation auditing, clinical documentation improvement (CDI), DRG clinical validation, HIM services, and interface/EHR support for healthcare providers. They employ only US-based, W-2 coders and auditors and emphasize coding accuracy, regulatory/compliance-focused audits, and integration with common EHR systems (EPIC, Meditech, CPSI). HCCS serves hospitals and healthcare partners with B2B services and also hires and trains coding professionals.

📋 Description

• Perform concurrent and retrospective reviews of inpatient medical records to improve the quality and accuracy of clinical documentation • Identify opportunities to clarify documentation that supports accurate code assignment, severity of illness, risk of mortality, quality metrics, and reimbursement • Collaborate with physicians through compliant query practices to obtain complete and accurate documentation • Partner with inpatient coding professionals to ensure documentation supports appropriate code assignment and accurate DRG assignment • Monitor assigned patient populations throughout hospitalization and perform follow-up documentation reviews as needed • Apply current CMS regulations, ICD-10-CM/PCS coding guidelines, MS-DRG methodologies, and Coding Clinic guidance • Promote provider education and documentation best practices that improve documentation integrity and patient outcomes • Analyze documentation trends and identify opportunities for process improvement • Participate in multidisciplinary collaboration to support documentation integrity initiatives • Maintain productivity, quality, and compliance standards established by HCCS and our client partners.

🎯 Requirements

• Active Registered Nurse (RN) license required • CCS, CIC, CDIP, and/or CCDS certification preferred, but not required • Minimum of three (3) years of recent Clinical Documentation Integrity (CDI) experience in a Level I Trauma Academic Medical Center or Teaching Hospital • Recent concurrent inpatient CDI experience required • Experience reviewing complex inpatient cases within a Level I Trauma academic healthcare environment required • Strong understanding of MS-DRGs, ICD-10-CM/PCS coding guidelines, severity of illness (SOI), risk of mortality (ROM), and compliant physician query practices • Experience collaborating directly with physicians and interdisciplinary clinical teams • Excellent critical thinking, analytical, and communication skills • Experience working within an electronic health record (Epic experience preferred, if applicable) • Must be authorized to work in the United States.

🏖️ Benefits

• Competitive compensation • Comprehensive benefits package • Supportive leadership • Opportunities for professional growth