Clinical Document Improvement Specialist

APR Consulting, Inc. has been engaged to identify a Clinical Document Improvement Specialist

Location: 2201 S Sterling St Morganton, NC 28655

Position: Clinical Document Improvement Specialist (100% Remote)

Pay Rate: $45.33/hr

Duration: 13-week Temp-to-Perm assignment

Expected Shift: Monday–Friday, 8:00 AM–5:00 PM ET for approximately 1–2 weeks

***After training: Flexible scheduling within 6:00 AM–6:00 PM ET, contingent upon meeting productivity and quality expectations***

IMPORTANT CALL OUTS:

• Minimum 3 years of Clinical Documentation Specialist experience in an inpatient acute-care environment is required
• Candidates must have direct inpatient CDI experience; inpatient coding experience alone does not satisfy the experience requirement
• Outpatient-only CDI experience will not qualify
• Candidate must already hold an active CCS, CDIP, or CCDS at the time of submission
• RN or nursing background is not required
• Candidates must demonstrate strong knowledge of clinical criteria and clinical validation
• Expected productivity is approximately 15–16 chart reviews per day, including initial and follow-up reviews
• Current team query average is approximately 60%
• Optum CAC is the primary system used
• Agency is responsible for providing equipment throughout the contract assignment
• UNC Health Blue Ridge will provide equipment if the candidate converts to permanent employment
• This is a temp-to-perm opportunity; candidates should be interested in permanent conversion
• Background check and drug screen are required
• Client is willing to waive applicable titers/clinical compliance items due to the fully remote nature of the position

REQUIRED QUALIFICATIONS:

EDUCATION:

• Healthcare-related education preferred
• Relevant experience may be considered in lieu of formal education
• Candidate must meet any education requirements associated with their professional certification

EXPERIENCE:

• Minimum 3 years of experience working as a Clinical Documentation Specialist in an inpatient acute-care hospital environment
• Strong experience performing inpatient clinical documentation integrity/improvement reviews
• Demonstrated ability to apply clinical criteria and clinical validation principles when reviewing inpatient records
• Experience identifying documentation opportunities and generating compliant provider queries
• Strong understanding of inpatient coding concepts and documentation requirements
• Experience reviewing documentation for severity of illness, risk of mortality, DRG impact, quality outcomes, and reimbursement
• Inpatient coding experience is beneficial as an additional background but does not replace the required 3 years of inpatient CDI Specialist experience
• Outpatient-only CDI or coding experience will not qualify

REQUIRED CERTIFICATION:

Candidate must have at least one of the following active at the time of submission:

• CCS – Certified Coding Specialist
• CDIP – Certified Documentation Integrity Practitioner
• CCDS – Certified Clinical Documentation Specialist

TECHNICAL SKILLS:

• Optum CAC experience preferred
• Strong knowledge of ICD-10-CM and ICD-10-PCS
• Knowledge of inpatient coding guidelines and applicable Coding Clinic guidance
• Strong understanding of:
• o Clinical criteria
• o Clinical validation
• o MS-DRGs
• o MCC/CC capture
• o Case Mix Index
• o Severity of Illness
• o Risk of Mortality
• o Compliant provider query practices
• Ability to efficiently navigate electronic medical records and CDI/coding technology in a fully remote environment

OTHER REQUIREMENTS:

• RN license or clinical nursing background is not required, but preferred
• Must demonstrate strong understanding of disease processes, clinical indicators, treatments, and associated procedures
• Strong written and verbal communication skills
• Ability to develop clear, compliant, non-leading provider queries
• Ability to collaborate with physicians, Coding, Quality, Revenue Cycle, Compliance, and other healthcare teams
• Ability to work independently in a fully remote environment
• Must consistently meet established productivity and quality expectations
• Must be available for the required 8:00 AM–5:00 PM ET training schedule during the first 1–2 weeks
• Candidate should be interested in and eligible for permanent conversion following the contract assignment

KEY RESPONSIBILITITES:

• Perform concurrent reviews of inpatient acute-care medical records to ensure documentation accurately reflects the patient’s clinical condition and services provided
• Complete approximately 15–16 chart reviews per day, including initial and follow-up reviews
• Apply established clinical criteria to assess whether documented diagnoses are clinically supported
• Identify incomplete, conflicting, ambiguous, or clinically unsupported documentation
• Develop and submit compliant, non-leading provider queries for clarification when appropriate
• Perform follow-up reviews and evaluate provider responses to queries
• Review documentation for accurate diagnosis and procedure capture and appropriate inpatient DRG assignment
• Identify documentation opportunities impacting:

MCC/CC capture

Case Mix Index

Severity of Illness

Risk of Mortality

Quality measures

Reimbursement

Regulatory reporting

• Collaborate with physicians and other clinical staff to improve the accuracy and completeness of inpatient documentation
• Partner with Coding, Quality, Revenue Cycle, Compliance, and related teams to support documentation integrity
• Provide education and guidance to providers regarding documentation requirements and identified improvement opportunities
• Support clinical validation, denial prevention, audits, and other CDI initiatives as assigned
• Maintain current knowledge of clinical criteria, coding guidelines, regulatory requirements, and CDI best practices
• Meet departmental productivity, query, quality, and accuracy expectations
• Maintain confidentiality and comply with applicable privacy, documentation, coding, and regulatory standards

Our client is the one of the largest Healthcare Staffing Provider in the United States, to be assigned at one of their affiliated hospitals/healthcare facilities.

This particular client is requiring that all new hires show proof of vaccination. However, accommodations may be made for those with disabilities or religious reasons who cannot obtain a vaccine.

Since 1980 APR Consulting, Inc. has provided professional recruiting and contingent workforce solutions to a diverse mix of clients, industries, and skill sets nationwide.

We are an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, pregnancy, age, national origin, disability status, genetic information, protected veteran status, or any other characteristic protected by law.

Don't miss out on this amazing opportunity! If you feel your experience is a match for this position please apply today and join our team. We look forward to working with you!