Clinical Documentation Improvement Specialist

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🔥 19 minutes ago

⛰️ Colorado – Remote

⛰️ Colorado – Remote

💵 $42 - $65 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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IMH

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2007

🤝 B2B

🏪 Marketplace

👥 B2C

B2B • Marketplace • B2C

IMH is the Groupe IMA entity providing end-to-end housing assistance and post-claim services across France. It operates 24/7 emergency call-taking and rapid-response interventions for home incidents (fires, water damage, electrical faults, locksmithing), offers remote damage expertise and cost estimation, and manages repair-in-kind through a national network of vetted contractors. IMH also runs digital platforms to support project estimation and paid home-service offerings, coordinates large-scale catastrophe responses, and connects insurers, beneficiaries and service providers via its accredited prestataire network.

📋 Description

• The Physician Advisor Services – CDI Specialist is responsible for improving the accuracy, completeness, and integrity of clinical documentation to ensure the medical record accurately reflects the patient’s clinical status, supports optimal patient care, and fulfills regulatory, quality, and reimbursement requirements. • Through concurrent and retrospective review, this role applies advanced clinical judgment and knowledge of documentation standards to identify clinical indicators, clarify diagnoses with providers, and ensure proper capture of severity of illness, risk of mortality, and risk adjustment variables. • The CDI Specialist partners closely with Clinical Documentation Integrity (CDI), Coding, Physician Advisors, Care Management, Quality, and regulatory teams to strengthen documentation performance across assigned facilities. • Performs comprehensive reviews of inpatient medical records to ensure documentation accurately reflects the patient’s clinical presentation, diagnoses, treatments, and outcomes. • Identifies opportunities to improve capture of SOI, ROM, HCC, CC/MCC, DRG accuracy, and risk adjustment elements. • Ensures clinical documentation supports the acuity represented in coding and reimbursement methodologies. • Collaborates with physicians and advanced practice providers to clarify ambiguous, incomplete, or conflicting documentation. • Provides education on documentation best practices, clinical criteria, and regulatory expectations. • Utilizes compliant query practices according to industry standards. • Applies Intermountain clinical program criteria, service line guidance, and national evidence-based clinical indicators to validate diagnoses. • Identifies documentation that does not meet clinical validation standards and engages providers appropriately. • Supports documentation requirements for quality programs, infection prevention, patient safety, and publicly reported measures. • Works closely with coding professionals to ensure accurate DRG assignment and alignment of documentation with coded data. • Partners with Physician Advisors to review complex clinical scenarios, documentation gaps, and medical necessity considerations. • Collaborates with Care Management to supply patient data needed for Utilization Review, Conditions of Participation, and status determinations. • Evaluates documentation for impacts on mortality metrics, PSI/HAC, infection prevention, VBP, CMS Star Ratings, and other publicly reported outcomes. • Ensures documentation supports both commercial and government payer requirements. • Identifies documentation gaps that may result in medical necessity or DRG-related denials. • Works with the Appeals Unit and Physician Advisors to support clinical appeal efforts and prevent payment denials. • Maintains CDI metrics including accuracy rates, clarification trends, compliance issues, and documentation outcomes. • Contributes to dashboards and analytics that inform CDI and PAS program priorities. • Supports data abstraction requirements for internal and external reporting.

🎯 Requirements

• Degree in a clinical field (e.g. RN, RRT, LCSW). • Education must be obtained through an accredited institution. Degree will be verified. • Three years of clinical experience in an adult acute care setting OR one year of experience as a Clinical Documentation Improvement Specialist in an adult acute care setting. • Proficiency in Quality and Infection Prevention reporting • Proficiency in Risk adjustment and Proactive Care Models • Experience with Microsoft Office products. • Clinical experience in ICU, CCU, primary care, or intermediate care. • Experience with Clinical Documentation Integrity. • Knowledge of EMR systems. • CCS, CIC, CCDS or CDIP

🏖️ Benefits

• We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.