Clinical Documentation Specialist 2 (Remote)

Clinical Documentation Specialist 2

Inova Benefits and Perks:

• Health, Vision, and Dental Coverage
• Tuition reimbursement and Educational Assistance
• Student loan assistance - up to $10,000!
• Paid parental leave for birth/adoption of a child
• Retirement benefits with match from day one
• Exclusive savings opportunities to in-store events, theme parks, discounts, movie tickets and local offerings and so much more!
• Competitive salary: Pay based experience
• Amazing Paid Time Off: Accrue PTO hours on your very first day of work

See Full List of Benefits Here: 2024 INOVA BENEFITS GUIDE

Inova Health System is seeking a Clinical Documentation Specialist to join the Central CDI team! This role is full-time Monday to Friday working remotely.

Requirements for consideration:

• Associate Degree (or RN, MD, RHIA, RHIT)
• 5 years of professional inpatient acute care, inpatient clinical, and/or coding experience required. Includes ICU, ER, Peds/NICU, case management/UR, quality or similar level of advanced care/coding.
• 2 years of CDI experience in an acute inpatient healthcare setting.
• CDI certification (CCDS or CDIP).
• RN, RHIT, or foreign medical school licensure documentation equivalent to educational background required.

Job Responsibilities included but not limited to:

• Performs initial case reviews and an appropriate number of follow-up reviews based on program standards. Uses clinical insight and judgment of clinical findings to assess clinical documentation for improvement opportunities. Independently develops complex queries. Follows up with the physician responsible for the care of the patient, via the query process, for clarification of clinical significance and appropriate documentation.
• Maintains query rate, response rate, and agreement rate in line with established performance benchmarks.
• Assists with reviewing records at different Inova hospitals as needed and under the supervision of assigned CDI leaders.
• Participates in all department-wide CDI and coding education on ICD-10, MS-DRG, and quality outcome measures as well as compliance requirements related to query (AHIMA Practice brief).
• Maintains competency in the use of CDI applications to process daily work lists and report results of record reviews and queries.
• Enters all required data into CDI applications to enable Coding professionals and Coding Quality Coordinators to determine the disposition of concurrent queries in order to assign the final MS-DRG as well as APR-DRG, SOI, and ROM and risk adjustment factors. Demonstrates expert knowledge of ICD 10 codes and MS-DRG/APR DRG assignments.
• Interacts with Coding Quality Coordinators and Coding professionals on any questions related to CDI working DRG related to concurrent queries and final coding.
• Assists with any post-discharge (retrospective) queries per CDI policy/procedure and as requested by CDI leadership.
• Demonstrates advanced technical ability with current software used by the department.
• Provides electronic support to providers regarding best practice documentation standards and the query process. Provides 1:1 provider education within the daily workflow and participates in group education sessions as requested by CDI Leadership.
• Participates in special projects, audits, and other duties as directed by CDI Leadership. May assist with precepting and education of new staff.
• As needed, may travel across the Washington DC metro area to engage with providers.
• May perform additional duties as assigned.