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About the role

Working primarily in a remote home environment, the full-time CDI Specialist will review medical records to ensure accurate documentation of clinical treatment and diagnoses, while collaborating with healthcare professionals to improve documentation practices.
Key responsibilities: Review medical records for completeness and compliance with regulatory requirements, ensuring accurate documentation of diagnoses and procedures Prepare and communicate compliant queries to physicians regarding missing or incomplete information in medical records Educate and collaborate with healthcare team members to promote correct coding and documentation practices
Required qualifications: Bachelor of Science in Nursing, Health Information Management, or a related field CCDS or CDIP certification preferred; RN/BSN or RHIA/RHIT with CCS considered 5 years of experience in Critical Care/Emergency medicine or Medical Surgical settings preferred 2-3 years of Clinical Documentation Improvement experience or 5 years of Coding experience preferred Familiarity with Medicare reimbursement systems and coding structures preferred

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