Clinical Documentation Improvement Specialist (FT- 1.0 FTE, Remote)

Approved Remote States:

1) Arizona

2) Florida

3) Georgia

4) Idaho

5) Iowa

6) South Dakota

7) Texas

8) South Carolina

9) Wisconsin

10) North Carolina 

11) Montana

Position Summary: 

The Clinical Documentation Improvement Specialist (CDIS) conducts concurrent reviews of inpatient medical records to enhance the quality, accuracy, and completeness of documentation. Utilizing clinical expertise and current coding systems (ICD-10-CM & PCS), the CDIS ensures proper code assignment and alignment with the patient’s clinical condition and care provided. The role involves collaborating with providers through education and the physician query process to support severity of illness, quality metrics, and regulatory compliance. Additionally, the CDIS maintains expertise in coding principles, government regulations, and third-party requirements while serving as a resource for clinicians, coders, and Revenue Cycle teams.

Minimum Qualifications:

Required:

• Bachelor's degree in Nursing (RN) or completion of an accredited or equivalent international medical program.
• Current licensure as a Registered Nurse (RN) or a graduate of an accredited advanced medical program (MD, DO, NP, MBBS, or equivalent).
• At least one of the following professional coding or documentation certifications:
  • Certified Coding Specialist (CCS)
  • Certified Clinical Documentation Specialist (CCDS)
  • Certified Documentation Improvement Practitioner (CDIP)
  • Registered Health Information Administrator (RHIA)
  • Registered Health Information Technician (RHIT)

Preferred:

• Three (3) years of experience in one of the following areas:
  • Medical/Surgical or Critical Care nursing.
  • Clinical Documentation Improvement (CDI) or Inpatient Coding in an acute care setting.

• Experience with Epic and 3M 360 Encoder systems.

Essential Job Functions:

In addition to the essential functions of the job listed below, employees must have on-time completion of all required education as assigned per DNV requirements, Bozeman Health policy, and other registry requirements.

• Ensure ethical, accurate, and complete coding by adhering to current coding practices, guidelines, and conventions when assigning DRGs, diagnoses, and procedures.
• Conduct concurrent medical record reviews for inpatient admissions, assigning a working principal diagnosis, secondary diagnoses, procedures, and DRG.
• Follow CDI processes for querying providers, reconciling DRG or diagnosis assignments with facility coders, and resolving physician queries before patient discharge.
• Collaborate with healthcare professionals, including physicians, advanced practice providers, case managers, and coders, to ensure documentation accurately reflects severity of illness, risk of mortality, and level of services provided.
• Utilize designated clinical documentation systems (e.g., 3M 360, Epic) to identify documentation improvement opportunities and enhance hospital outcomes.
• Identify medical record data integrity issues and escalate concerns related to coding, CDI functions, or electronic health record (EHR) systems to the appropriate department.
• Maintain compliance with HIPAA regulations to ensure data security and patient confidentiality.
• Participate in team, clinician, and interdepartmental meetings, as well as training, shadowing, and education initiatives for staff related to compliance, coding, and CDI best practices.
• Provide education and act as a consultant to coders and clinical staff when additional documentation or clarification is needed for accurate DRG assignment and coding compliance.
• Identify and recommend process improvements and efficiencies within CDI and coding workflows while monitoring and reporting patterns, trends, and variances in documentation.
• Generate scheduled reports and other reports as requested to track CDI effectiveness and documentation trends.
• Stay up to date with CMS regulations and industry best practices, researching literature and incorporating changes into daily CDI practice.
• Meet productivity and quality standards as designated by the System Manager of CDI and complete special projects as assigned.

Knowledge, Skills and Abilities

• Demonstrates sound judgment, patience, and maintains a professional demeanor at all times
• Exercises tact, discretion, sensitivity, and maintains confidentiality
• Performs essential job functions successfully in a busy and stressful environment
• Learns current and new computer applications and office equipment utilized at Bozeman Health
• Strong interpersonal, verbal, and written communication skills
• Analyzes, organizes, and prioritizes work while meeting multiple deadlines

Schedule Requirements

• This role requires regular and sustained attendance.
• The position may necessitate working beyond a standard 40-hour workweek, including weekends and after-hours shifts.
• On-call work may be required to respond promptly to organizational, patient, or employee needs.

Physical Requirements

• Lifting (Rarely – 30 pounds): Exerting force and/or using a negligible amount of force to lift, carry, push, pull, or otherwise move objects or people.
• Sit (Continuously): Maintaining a sitting posture for extended periods may include adjusting body position to prevent discomfort or strain.
• Stand (Occasionally): Maintaining a standing posture for extended periods may include adjusting body position to prevent discomfort or strain.
• Walk (Occasionally): Walking and moving around within the work area requires good balance and coordination.
• Climb (Rarely): Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like using feet and legs; may also use hands and arms.
• Twist/Bend/Stoop/Kneel (Occasionally): Twisting, bending, stooping, and kneeling require flexibility and a wide range of motion in the spine and joints.
• Reach Above Shoulder Level (Occasionally): Lifting, carrying, pushing, or pulling objects as necessary above the shoulder, requiring strength and stability.
• Push/Pull (Occasionally): Using the upper extremities to press or exert force against something with steady force to thrust forward, downward, or outward.
• Fine-Finger Movements (Continuously): Picking, pinching, typing, or otherwise working primarily with fingers rather than using the whole hand as in handling.
• Vision (Continuously): Close visual acuity to prepare and analyze data and figures and to read computer screens, printed materials, and handwritten materials.
• Cognitive Skills (Continuously): Learn new tasks, remember processes, maintain focus, complete tasks independently, and make timely decisions in the context of a workflow.
• Exposures (Rarely): Bloodborne pathogens, such as blood, bodily fluids, or tissues. Radiation in settings where medical imaging procedures are performed. Various chemicals and medications are used in healthcare settings. Job tasks may involve handling cleaning products, disinfectants, and other substances. Infectious diseases due to contact with patients in areas that may have contagious illnesses.

*Frequency Key:  Continuously (100% - 67% of the time), Repeatedly (66% - 33% of the time), Occasionally (32% - 4% of the time), Rarely (3% - 1% of the time), Never (0%).