RN – Clinical Documentation Integrity Specialist

🔥 0 minutes ago

🌽 Illinois – Remote

🌽 Illinois – Remote

💵 $34 - $59 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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Carle Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1946

⚕️ Healthcare Insurance

🏥 Healthcare

📚 Education

Healthcare Insurance • Healthcare • Education

Carle Health is a comprehensive healthcare provider dedicated to managing the health needs of its community. Offering a wide range of services, from general medical care to specialized treatments in oncology, cardiovascular, pediatrics, and women's health, Carle Health emphasizes quality patient care and community health initiatives. Additionally, it supports education and research through the Carle Illinois College of Medicine and engages in community health programs that aim to improve overall well-being.

📋 Description

• Performs inpatient chart review to determine appropriate DRG assignment and ensure documentation supports clinical care, severity of illness, and risk of mortality • Coordinates with physicians, nurses, ancillary staff, and Health Information Management coders to identify and record diagnoses, procedures, and working DRGs • Performs second-level review of assigned DRGs • Provides education on CDI topics to peers, providers, and clinicians • Reviews DRG denials and provides information to the denials team for appeals • Conducts comprehensive, concurrent, and retrospective reviews of inpatient accounts • Identifies missing, unclear, or conflicting documentation affecting DRG assignment, SOI/ROM, mortality, PSI, quality metrics, and clinical outcomes • Develops and issues compliant, clinically supported physician queries • Provides guidance and training to providers and clinicians on DRG and documentation opportunities • Supports quality reporting, CDI program development, and regulatory compliance initiatives • Participates in audits, data validation, and performance projects • Uses EPIC and CDI software workflows, follows up on open queries, and reports issues to leadership • Participates in testing upgrades as an expert when needed • Attends required education sessions

🎯 Requirements

• Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) • Certified Clinical Documentation Specialist (CCDS) within 1 year - Association of Clinical Documentation Integrity Specialists (ACDIS) • Certified Coding Specialist (CCS) within 1 year - American Health Information Management Association (AHIMA) • Registered Health Information Technician (RHIT) - American Health Information Management Association (AHIMA) • Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA) • Licensed Physician (MD) - Illinois Department of Financial and Professional Regulation (IDFPR) • Doctorate: Medicine • College Diploma: Health Information Mgt • College Diploma: Nursing • Work experience in CDI, coding, or clinical bedside care • Strong knowledge of ICD-10 guidelines • Knowledge of electronic health record (EHR) systems • Excellent communication skills to interact with physicians • Advanced knowledge of clinical guidelines, coding updates, and CDI best practices • Ability to support documentation efforts using clinical knowledge and coding guidelines • Ability to use EPIC scoring tools and CDI software • Ability to meet production standards and established query turnaround times • Ability to maintain educational hours needed to re-certify credentials

🏖️ Benefits

• Comprehensive benefits package • Day shift schedule, Monday-Friday • No holiday requirements • No on-call requirements • Opportunities for growth and life-long careers • Equal opportunity employment