Clinical Documentation Improvement Specialist 3.3 3.3 out of 5 stars Arizona • Remote InSync Consulting is seeking a highly skilled Clinical Documentation Specialist (CDS) with a strong clinical background to join our remote team. This position plays a key role in ensuring the accuracy and completeness of clinical documentation in patient medical records. As a CDS, you will collaborate closely with physicians, allied health professionals, health information management teams, and nursing staff to ensure the medical record truly reflects the patient's clinical status. The ideal candidate will have a solid understanding of MS-DRG and APR-DRG classification, Quality Data elements, and Risk Adjustment tools, with a focus on enhancing documentation accuracy and compliance in alignment with CMS regulations.

Key Responsibilities:

Conduct thorough clinical record reviews to ensure accurate and comprehensive documentation. Collaborate with physicians, nurses, and healthcare professionals to improve clarity and completeness of clinical documentation. Apply MS-DRG and APR-DRG classification to ensure compliance with CMS guidelines. Utilize quality-based review processes including mortality reviews and risk adjustment tools. Educate and guide providers and clinical staff on best practices for documentation improvement. Work remotely, ensuring effective communication and teamwork in a virtual setting.

Requirements:

Medical degree (IMG) or RN license (Required). Minimum of 2 years of Clinical Documentation Improvement (CDI) experience in a complex acute care setting (Required). Preferred experience in OBGYN, Pediatrics, and Inpatient Psychiatry . Familiarity with quality-based reviews, mortality reviews, and risk adjustment tools. Strong communication skills, with the ability to collaborate effectively in a remote team environment.

Job Types:

Full-time, Contract Pay:

$58.73 - $62.25 per hour

Benefits:

Health insurance

Schedule:

8 hour shift Day shift

Experience:

Clinical documentation improvement: 2 years (Required)

OBGYN, Pediatrics and Inpatient Psychiatry:

1 year (Preferred)

License/Certification:

Medical Degree (IMG) or RN License (Required)

Work Location:

Remote