Society of Trauma Nurses
Clinical Documentation Specialist (CDI) RN, CCDS, or CDIP
Society of Trauma Nurses, New Orleans, Louisiana, United States, 70123
Clinical Documentation Specialist (CDI) – RN, CCDS, or CDIP
Full-Time | Remote
Position Summary We are seeking an experienced Clinical Documentation Specialist (CDI) to join our team in a full-time, fully remote capacity.
The ideal candidate will have 3+ years of CDI experience, with demonstrated expertise in Behavioral Health, OB/NICU, and comprehensive chart reviews.
Key Responsibilities
Conduct concurrent and/or retrospective reviews of inpatient medical records to ensure accurate clinical documentation.
Identify documentation gaps related to diagnoses, procedures, severity of illness, and risk of mortality.
Issue compliant, clinically appropriate provider queries in accordance with ACDIS/AHIMA guidelines.
Collaborate with physicians, nursing staff, and interdisciplinary teams to improve documentation quality.
Apply ICD-10-CM/PCS coding knowledge to support accurate documentation and reporting.
Maintain productivity and quality standards while working independently in a remote environment.
Stay current with regulatory requirements, coding guidelines, and CDI best practices.
Required Qualifications
Active RN license or CCDS certification.
Minimum 3 years of CDI experience.
Proven CDI experience in:
Behavioral Health OB/NICU Comprehensive chart reviews
Strong clinical knowledge and critical thinking skills.
Solid understanding of ICD-10-CM/PCS, MS-DRGs, SOI/ROM, and quality measures.
Excellent written and verbal communication skills.
Ability to work independently in a fully remote environment.
Preferred Qualifications
Experience with multiple EHR systems.
Prior remote CDI experience.
RN, CCDS, or CDIP certification.
What We Offer
100% remote work environment.
Full-time, stable employment.
Competitive compensation.
Full Benefits / PTO.
Supportive and collaborative CDI team.
Opportunities for professional growth and development.
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Position Summary We are seeking an experienced Clinical Documentation Specialist (CDI) to join our team in a full-time, fully remote capacity.
The ideal candidate will have 3+ years of CDI experience, with demonstrated expertise in Behavioral Health, OB/NICU, and comprehensive chart reviews.
Key Responsibilities
Conduct concurrent and/or retrospective reviews of inpatient medical records to ensure accurate clinical documentation.
Identify documentation gaps related to diagnoses, procedures, severity of illness, and risk of mortality.
Issue compliant, clinically appropriate provider queries in accordance with ACDIS/AHIMA guidelines.
Collaborate with physicians, nursing staff, and interdisciplinary teams to improve documentation quality.
Apply ICD-10-CM/PCS coding knowledge to support accurate documentation and reporting.
Maintain productivity and quality standards while working independently in a remote environment.
Stay current with regulatory requirements, coding guidelines, and CDI best practices.
Required Qualifications
Active RN license or CCDS certification.
Minimum 3 years of CDI experience.
Proven CDI experience in:
Behavioral Health OB/NICU Comprehensive chart reviews
Strong clinical knowledge and critical thinking skills.
Solid understanding of ICD-10-CM/PCS, MS-DRGs, SOI/ROM, and quality measures.
Excellent written and verbal communication skills.
Ability to work independently in a fully remote environment.
Preferred Qualifications
Experience with multiple EHR systems.
Prior remote CDI experience.
RN, CCDS, or CDIP certification.
What We Offer
100% remote work environment.
Full-time, stable employment.
Competitive compensation.
Full Benefits / PTO.
Supportive and collaborative CDI team.
Opportunities for professional growth and development.
#J-18808-Ljbffr