Clinical Documentation Improvement Specialist

Job not on LinkedIn

🔥 1 minute ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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👻 Ghost score 12%

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DeliverHealth

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

⚕️ Healthcare Insurance

🤖 Artificial Intelligence

Healthcare • Healthcare Insurance • Artificial Intelligence

DeliverHealth is an innovative company that specializes in providing advanced technology solutions and services to improve healthcare operations. They focus on enhancing healthcare documentation and coding through the use of AI and generative languages. Their offerings include eSOne InstaNote for AI-generated healthcare documentation, autonomous coding with AI, digital health solutions to boost patient engagement, and seamless EHR integration. DeliverHealth is known for their expertise in reducing administrative burdens, improving patient care, and integrating digital healthcare platforms, all while ensuring data security with HITRUST i1 certification.

📋 Description

• Review and validate CDI recommendations generated by InstaNote for clinical accuracy, encounter relevance, documentation support, provider actionability, and coding/reimbursement value • Evaluate AI-generated clinical notes for missing diagnoses, documentation specificity, medical decision-making, diagnostic support, clinical evidence, and missed CDI opportunities • Conduct routine CDI feature audits measuring accuracy, precision, recall, false positive rate, false negative rate, missed opportunities, clinical relevance, specialty appropriateness, provider usability, and recommendation acceptance potential • Document findings in standardized quality scorecards • Partner with Product Management and Engineering teams to provide structured feedback on incorrect recommendations, missing clinical logic, new documentation scenarios, specialty patterns, prompt improvements, knowledge gaps, AI workflow enhancements, user experience, and prioritization • Participate in regular AI quality review sessions • Create and maintain gold-standard annotated clinical cases, specialty-specific documentation examples, recommendation libraries, clinical review guidelines, evaluation datasets, and reference documentation standards • Review CDI recommendations across Orthopedics, Emergency Medicine, Urgent Care, Primary Care, Cardiology, Internal Medicine, Behavioral Health, Pediatrics, and Surgical Specialties • Recommend specialty-specific enhancements to improve AI performance • Collaborate with Product Managers, AI Engineers, Prompt Engineers, Machine Learning Engineers, Medical Coders, Clinical Informaticists, QA Engineers, and Data Scientists • Translate clinical observations into product requirements and acceptance criteria • Produce weekly validation reports, clinical quality scorecards, false positive/negative analyses, missed opportunity reports, root cause analyses, product enhancement recommendations, annotated reference cases, specialty-specific feedback reports, monthly AI performance trend reports, and clinical acceptance criteria

🎯 Requirements

• Bachelor's degree in Nursing, Health Information Management, Medicine, Physician Assistant Studies, or a related clinical field • 5+ years of Clinical Documentation Improvement experience • Experience reviewing physician documentation for coding quality and documentation completeness • Strong knowledge of ICD-10-CM coding principles • Experience with HCC and Risk Adjustment documentation • Familiarity with outpatient and ambulatory documentation practices • Experience working with physicians on documentation quality initiatives • Exposure to AI-assisted clinical documentation solutions is preferred • Preferred credentials include RN / BSN, RHIA, RHIT, PA, NP, MD / DO (preferred but not required) • Strong understanding of Clinical Documentation Improvement, ICD-10-CM, HCC, Risk Adjustment, CPT coding fundamentals, documentation specificity, medical necessity, clinical terminology, provider documentation workflows, AI-assisted documentation tools, and Electronic Health Records such as Epic, athenahealth, Cerner, and eClinicalWorks • Strong clinical judgment, excellent analytical skills, attention to detail, ability to identify documentation gaps, root cause analysis, data-driven decision making, effective written communication, cross-functional collaboration, continuous improvement mindset, and passion for healthcare AI and clinical innovation