Clinical Documentation Integrity Specialist

🔥 9 minutes ago

🏖️ New Jersey – Remote

🏖️ New Jersey – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

👻 Ghost score 10%

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Med-Metrix

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2010

🏥 Healthcare

☁️ SaaS

💰 Private equity on 2025-09

Healthcare • SaaS

Med-Metrix is a company for which only a minimal web presence was provided (the page only displayed "Loading application... Your web browser must have JavaScript enabled... "). No product, market, or mission details were included in the supplied text. Based on the company name alone, it plausibly focuses on medical or clinical metrics, analytics, or healthcare software, but that is speculative and not confirmed by the provided information. Further public details would be required to be more specific.

📋 Description

• Analyze medical records to identify incomplete, inconsistent, or inaccurate documentation related to diagnoses, treatments, procedures, severity of illness, and risk of mortality • Perform concurrent chart reviews to ensure clinical documentation accurately reflects the patient’s condition, complexity of care, and services rendered to support appropriate coding and reimbursement • Facilitate clarification and modification of clinical documentation through concurrent interaction with physicians and members of the healthcare team • Analyze coding and documentation data to identify trends, variations, and opportunities for documentation improvement, and communicate findings to management • Utilize data analytics, DRG reports, and tracking tools to monitor documentation performance and support performance improvement initiatives • Collaborate with physicians, nurses, coders, and other healthcare professionals to clarify documentation and obtain additional information • Support coding teams by ensuring documentation supports code assignment and complies with coding guidelines and regulatory requirements • Communicate with coding staff and healthcare providers to resolve coding-related issues • Conduct training and educational sessions for providers and staff on documentation best practices, coding guidelines, compliance requirements, and quality initiatives • Demonstrate knowledge of quality measure initiatives, including Value-Based Purchasing, Pay-for-Performance, readmission reduction programs, and related regulatory requirements • Ensure clinical documentation aligns with organizational policies, coding standards, regulatory requirements, and payer guidelines • Conduct routine audits and reviews of clinical documentation to evaluate quality, accuracy, and compliance • Participate in quality improvement initiatives focused on clinical documentation integrity, coding accuracy, and operational performance • Use, protect, and disclose patients’ protected health information only in accordance with HIPAA standards • Comply with Information Security and HIPAA policies and procedures • Limit viewing of PHI to the absolute minimum necessary to perform assigned duties • Perform other duties as assigned

🎯 Requirements

• BSN or PA (Physician's Assistant) or NP (Nurse Practitioner) or Doctorate degree in a medically related field required • High school diploma or equivalent required • Minimum of 3 years of experience in clinical documentation improvement role required • Minimum of 5 years nursing experience in adult acute care in med/surg, critical care, emergency, or PACU required • Active RN, MD, DO, NP, or PA license required • Certification minimum requirement – CCDS and/or CDIP • Coding credential (CCS, CPC, CCS-P) is a plus • Current state Registered Nurse license highly preferred • Clinic fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems • Proficient in CDI tools such as encoder or CDI workflow and reporting tool • Proficiency in Microsoft Office Suite • Strong interpersonal skills, ability to communicate well at all levels of the organization • Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses • High level of integrity and dependability with a strong sense of urgency and results oriented • Excellent written and verbal communication skills required • Must possess a smart-phone or electronic device capable of downloading applications • Must be able to follow directions, collaborate with others, and handle stress

🏖️ Benefits

• Remote work arrangement • Smartphone or electronic device capable of downloading applications for multifactor authentication and security purposes