Description
Employment Type: Full-Time
Schedule: Monday through Friday, Day Shift
Work Location: Remote (U.S. based)
Position Summary
We are seeking a dedicated and detail-oriented Clinical Documentation Nurse (CDI Nurse) to join our remote team. This position plays a critical role in improving the quality and completeness of clinical documentation to support accurate coding, quality measures, and regulatory compliance. This role is responsible for conducting comprehensive clinical documentation reviews that impact severity of illness (SOI), risk of mortality (ROM), Hospital-Acquired Conditions (HACs), and Patient Safety Indicators (PSIs). The goal is to ensure the medical record accurately reflects the patient’s clinical status and supports the highest level of specificity for coding, quality reporting, and regulatory compliance. The ideal candidate will possess strong clinical judgment, analytical skills, and a passion for improving patient care documentation.
Requirements
Key Responsibilities
- Perform comprehensive clinical documentation reviews for all inpatient encounters, focusing on SOI, ROM, HACs, PSIs, and risk adjustment factors.
- Identify documentation gaps and opportunities to improve the accuracy and completeness of the medical record.
- Initiate compliant queries to providers for clarification or additional specificity to support appropriate diagnosis capture and DRG assignment.
- Collaborate with providers, coding professionals, and case management to support alignment between clinical documentation and coding.
- Monitor trends in documentation quality, query opportunities, and provider response rates.
- Ensure documentation supports metrics used in quality reporting, reimbursement, and publicly reported outcomes.
- Ensure documentation aligns with ICD-10-CM/PCS, MS-DRG, APR-DRG, and other relevant coding and reimbursement guidelines.
- Maintain expertise in CMS guidelines, AHRQ PSIs, coding rules, and regulatory changes.
Qualifications
- Active RN license in [State]
- CDI-related certification (e.g., CCDS, CDIP, or equivalent
- 2 years of experience in Clinical Documentation Improvement or medical record review
- Familiarity with electronic health record (EHR) systems and CDI software
- Knowledge of coding systems (ICD-10, MS-DRG, APR-DRG) and CMS guidelines
- Strong knowledge of medical terminology, anatomy, pathophysiology, and pharmacology
- Familiarity with HAC and PSI definitions, risk-adjusted outcome measures, and quality reporting programs.
- Strong analytical, critical thinking, and clinical judgment skills.
- Excellent verbal and written communication skills with experience querying providers.
- Proficiency with EHR systems and CDI software.