Supervises daily operations of the Clinical Documentation Integrity program for Health Ministries within the region, overseeing staff, ensuring compliance, and driving quality improvement.
Compensation
(Hourly pay range: $47.2309-$70.8464)
Responsibilities
Supervise daily operations of the CDI team
Ensure compliance with program standards and policies
Coordinate performance improvement initiatives
Provide training and education to CDS staff
Manage scheduling and staffing assignments
Requirements
Bachelor’s Degree in Health Information Management, Healthcare related field or Nursing or equivalent
Nice to have: Certified Clinical Documentation Specialists (CCDS)
Nice to have: Certified Documentation Improvement Professional (CDIP)
Concurrently and retrospectively reviews inpatient medical records to identify the most appropriate principal diagnosis and to assign a working DRG.
Completes the initial review within 24 hours of admission.
Completes concurrent reviews to ensure working DRG and all comorbid conditions are documented by the providers to the greatest specificity.
Ensures documentation supports diagnoses.
Collaborates with the coding staff concurrently and retrospectively to ensure the chart has all the necessary documentation to support the most accurate coding.
Requirements
ASN or Associate of Science in Health Information Management
Advanced degrees in Nursing or Health Information Management
Responsible for extensive record review, interaction with physicians, HIM coding professionals, nursing staff and other patient care givers to ensure accurate representation of patient severity of illness and quality of care.
Responsibilities
Provides extensive and accurate reviews of medical records within specified timelines
Recognizes opportunities for documentation improvement to support severity of illness and quality of care
Follows up on all cases especially those with clinical documentation clarifications/queries
Provides education to providers on responding to queries in the medical record and other CDI topics
Participates in Coding/CDI meetings and CDI H3W work group
Requirements
Associates Degree or equivalent
Nice to have: Registered Nurse with 8+ years acute care experience
Nice to have: 2+ years experience as a CDS
Nice to have: Certified Clinical Documentation Specialist (CCDS)
Nice to have: Certified Clinical Documentation Professional (CDIP)
The HIM Coding Auditor-Educator serves as a knowledge expert and leader for ICD-10-CM/PCS and CPT-4 classification systems coding quality and education.
Responsibilities
Develops, coordinates, and maintains coding education and training programs based on audit findings, regulatory updates, identified knowledge gaps, and coding quality trends.
Performs and analyzes inpatient and outpatient ICD-10-CM/PCS and CPT coding quality reviews to validate accurate DRG assignment, Severity of Illness, Present on Admission indicators, principal diagnosis, procedures, and reportable secondary diagnoses in accordance with official coding guidelines and organizational policies.
Requirements
Bachelor’s Degree in HIM, Business or related field required.
Develop and issue compliant physician queries based on clinical indicators, coding guidelines, and documentation gaps.
Review medical records to identify opportunities for clarification that impact DRG assignment, SOI/ROM, and reimbursement integrity.
Ensure all queries adhere to AHIMA and ACDIS standards for compliance and neutrality.
Track and follow up on outstanding queries to ensure timely response and resolution.
Collaborate with CDI professionals and inpatient coders to align documentation with coding and regulatory requirements.
Requirements
Bachelor’s degree or equivalent experience required
Clinical background or training as a Registered Nurse, Nurse Practitioner, Occupational Therapist, Physical Therapist, Physician Assistant, or Physician
Supports Second Wave Delivery Systems’ mission to ensure accurate clinical documentation, appropriate reimbursement, and quality of care through review of quality measures and drafting of physician queries.
Compensation
Compensation Range: $95,000 – $120,000
Responsibilities
Review inpatient records flagged for Patient Safety Indicators to validate clinical support and identify documentation or coding opportunities
Review mortality cases to ensure accurate capture of severity of illness, risk of mortality, comorbidities, and palliative or hospice status
Review records for CMS Core Measures to identify documentation gaps and ensure measure-related documentation is complete and accurate
Recommend coding changes or physician queries where documentation does not support or fully explain a quality event
Track and report findings, trends, and outcomes from quality reviews to support client reporting and provider education
Requirements
Bachelor's degree
Nice to have: CCDS credential
Nice to have: CDIP credential
Nice to have: experience with quality measure review
The Inpatient Coding Quality Auditor is an exempt professional role responsible for independently evaluating the accuracy, consistency, compliance, quality, and effectiveness of inpatient coding activities across City of Hope.
The Clinical Documentation Specialist is responsible for facilitating accurate and compliant documentation by improving the overall quality and completeness of the medical record. Through utilization of clinical expertise, this role ensures the patient’s severity of illness is captured in the medical record.
Responsibilities
Analyze clinical documentation for assigned patients and make recommendations for appropriate DRG assignment.
Facilitate appropriate clinical documentation to support accurate diagnosis coding and ensure the level of service rendered is fully recorded.
Complete admission reviews with the most appropriate principal diagnosis, complicating conditions, and supporting documentation to reflect severity of illness in compliance with government regulations.
Identify opportunities for documentation clarification and complete clinically based queries.
Perform timely follow-up on outstanding queries and document outcomes appropriately.
The CDI Specialist is responsible for comprehensive secondary clinical chart reviews to identify potential missed opportunities for documentation clarification. Collaborates closely with Coders, Coding Educators, Coding Quality Auditors, Case managers, Quality Department and Providers to assure documentation is clinically appropriate, accurately reflects the severity of illness and risk of mortality for the patient and is reflective of current CMS or other regulatory standards.
Compensation
The annual salary range for this position is $61,000.00-$101,000.00.
Responsibilities
Conduct comprehensive secondary clinical chart reviews to identify potential missed opportunities for documentation clarification.
Conduct daily, concurrent review of inpatient records on assigned unit(s) to ensure complete and accurate physician and or clinician documentation is present at the time of discharge for accurate, timely, and compliant coding.
Reviews daily admissions to assigned unit, perform initial code assignment for a working DRG and complete CDI software data entry for initial and follows up case reviews.
Updates 'working DRG' as documentation supports, or physician query answer supports a change in the DRG assignment.
Communicates to the CDI Coordinator when volume of daily review assignments is too high or low.
Conduct routine, targeted, pre-bill, and retrospective coding audits to evaluate coding accuracy, DRG assignment accuracy, abstraction quality, coding compliance, reimbursement integrity, and adherence to Official Coding Guidelines, Coding Clinic guidance, CMS regulations, payer requirements, and City of Hope coding standards.
Monitor coding compliance risk areas, Coding Clinic updates, CMS guidance, payer audit findings, OIG Work Plan priorities, RAC-targeted services, denial trends, and emerging regulatory requirements.
Provide recommendations to support regulatory readiness and coding excellence.
Complete assigned work within established productivity and turnaround time expectations to support candidate-for-bill (CFB), DNFB, revenue cycle, and organizational performance goals.
Clinical Documentation Spec 1 / HIM Clinical Document MgmtThe Hospital of Central Connecticut · Farmington, US
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CLINICAL DOCUMENTATION SPECPremier Health · Dayton, US