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Associate Clinical Documentation Improvement Specialist

Remote, USA Full-time Posted 2025-11-03
About the position Responsibilities • Perform concurrent and retrospective chart reviews for improving the overall completeness of clinical documentation • Keep abreast of current coding trends and maintains up to date knowledge of Medicare rules and regulations regarding diagnosis coding and CDI current trends • Effectively utilizes ICD-10 and related materials to investigate coding issues and produce accurate results • Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity • Provides expert level leadership for overall improvement in clinical documentation by providing proficient level review and assessment, and effectively articulating recommendations for improvement, and the rational for the recommendations • Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality • Provides complete follow through on all requests for clarification or recommendations for improvement • Ensures effective utilization of Optum® CDI 3D Technology to document all clarification activity • Utilizes only the Optum360 approved clarification forms • Proactively develops a reciprocal relationship with the HIM Coding Professionals • Engages and consults with Physician Advisor /VPMA when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process Requirements • Must be 18 years of age or older • Registered Nurse with 3+ years of clinical acute care hospital OR care coordination experience OR Medical Graduate with CDI (Clinical Documentation Integrity) experience • Understanding of clinical medicine, pathophysiology, and pharmacology • Proficiency using a PC in a Windows environment, including Microsoft Word, Microsoft Excel, Microsoft PowerPoint • Ability to work full-time. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00am - 5:00pm with one weekend shift (Saturday or Sunday) as well. It may be necessary, given the business need, to work occasional overtime. Nice-to-haves • 5+ years of acute inpatient hospital coding with certifications • 5+ years acute care hospital clinical RN experience OR Medical Graduate with CDI experience and CDI certification (CCDS, CDIP) • 3+ years of CDI experience for an acute care hospital • BSN degree if a RN • Grasp of ICD-10 coding, coding conventions, and guidelines • CAC experience (Computer Assistant Coding) Benefits • Comprehensive benefits package • Incentive and recognition programs • Equity stock purchase • 401k contribution Apply tot his job Apply To this Job

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