Uasi
Clinical Documentation Integrity Specialist
Remote. Posted 2 months ago
The role
This person will review and evaluate medical record documentation for completeness, accuracy, and compliance. They will collaborate with physicians, nurses, and coding professionals to support coding accuracy, reimbursement, and clinical outcomes.
What you will do
- Review and evaluate medical record documentation for completeness, accuracy, and compliance.
- Collaborate with physicians, nurses, and coding professionals to ensure appropriate clinical documentation.
- Identify opportunities for documentation improvement to support coding accuracy, reimbursement, and clinical outcomes.
- Analyze medical records to ensure documentation supports quality care and appropriate reimbursement.
- Formulate compliant, clinically sound physician queries.
Required qualifications
- Minimum of 2 years of inpatient clinical documentation improvement (CDI) experience
- Minimum of 2 years of bedside nursing experience in an acute care setting (ICU, Med/Sure, ED, Etc.)
- Registered Nurse (RN)
- Knowledge of ICD-10-CM, MS-DRGs, coding guidelines, and compliance standards.
- Excellent communication, critical thinking, and organizational skills.
- Comfortable using MS Office, email, VPNs, virtual machines, two-factor authentication, and video conferencing tools (MS Teams, Zoom, etc.)
Nice to have
- Utilization of 3M and Epic software
- CCDS/CDIP
Benefits
- full benefits package
- PTO
- top pay
- Collaborative, mission-driven team environment
- Opportunities for continuous learning, education and professional growth
- Leadership that values your expertise and input
About the company
UASI is driven by a mission to improve the quality and accuracy of clinical documentation through expert CDI consulting.