Clinical Documentation Improvement (CDI) With Integrity Exp.

Job Title: Clinical Documentation Improvement (CDI)

Location: Remote

Duration: 12+Months

Start Date: ASAP.

Job Description:

Mandatory Skills : Integrity, Clinical Documentation Improvement (CDI)

• Review inpatient and/or outpatient medical records for completeness and accuracy.
• Identify documentation gaps related to diagnoses, procedures, complications, CC/MCC.
• Ensure compliance with guidelines from Centers for Medicare & Medicaid Services (CMS).
• Clarify ambiguous or incomplete documentation through physician queries.
• Support accurate ICD-10-CM/PCS coding and DRG assignment.
• Educate providers on documentation best practices.
• Assist with Risk Adjustment (HCC) documentation.
• Monitor Severity of Illness (SOI) and Risk of Mortality (ROM).
• Participate in quality improvement initiatives.
• Maintain productivity and quality metrics.