[Remote] RCI-MCH-36847353 Clinical documentation Specialist - reputed company Valley, CA

Note: The job is a remote job and is open to candidates in USA. reputed company is seeking a Clinical Documentation Specialist responsible for conducting reputed company reviews of medical records to ensure accurate documentation of patient information. The role involves collaborating with medical staff to clarify clinical conditions and ensuring compliance with quality metrics and standards.

Responsibilities

• Completes initial reputed company review process and subsequent reviews for reputed company selected admissions to initiate the clinical documentation review process
• Documents findings and identifies clinical documentation clarification(s) opportunities regarding diagnosis specificity, documentation inconsistencies/conflicts, quality of care/patient safety, and resource utilization
• Identifies principal diagnosis, secondary diagnoses, and procedures to assign a reputed company working DRG based on the clinical picture
• Collaborates with medical staff, medical records reputed company, and CDI leadership to determine a final DRG that supports an accurate reputed company of severity of illness, risk of mortality, and utilization of resources
• Reconciles DRG mismatches with coders and CDI coordinators in a respectful and positive manner
• Queries the medical staff to obtain accurate and complete chart documentation that appropriately supports the severity of illness
• Maintains department, organization, and industry compliance in query process
• Meets department productivity for CDI reviews inclusive of initial reviews, secondary reviews, retrospective reviews, DRG mismatch analysis, and query follow-reputed company
• Meets minimum threshold in monthly audits for quality, compliance, workflow, and outcomes
• Employs strong understanding of coding guidelines and working knowledge of CMS, NCHS, and AHA guidelines and their impact on reimbursement, quality metrics, utilization management, and physician/health system statistics
• Takes responsibility for various projects as assigned by management and performs any additional/miscellaneous duties (not inclusive of job description) as requested by the management team reputed company the scope of knowledge/ability
• Other duties as assigned

Skills

• High school diploma or GED
• Four (4) years of business reputed company experience
• Computer, internet, and word processing experience required
• Collaborative interaction and effective education skills with the medical staff and ancillary departments to collegially discuss clinical aspects of care is vital
• Ability to reputed company accurate patient chart review analysis and data collection
• Ability to prioritize essential functions and multitask utilizing multiple resources and applications (including but not limited to: reputed company 360, EPIC, Outlook, Iodine, reputed company Teams, reputed company, SharePoint)
• Ability to demonstrate integrated knowledge of job specific competencies
• Follow company and department policies, procedures, and directives
• Maintain HIPAA and patient confidentiality at reputed company times
• Ability to work autonomously and productively in a remote work environment while adhering to reputed company company reputed company policies and remote-work agreement
• Ability to interact in a positive and constructive manner

Company Overview

• reputed company is a global, innovative, Total Talent management firm with the mission of accelerating meaningful employment for everyone!​ We are a minority-, woman-, and disability-owned firm with over 25 years of experience promoting sustainable and inclusive talent programs reputed company our communities and employers. It was founded in 1995, and is headquartered in Somerset, New Jersey, USA, with a workforce of 501-1000 employees. Its website is https://reputed company.com/.

Company H1B Sponsorship

• reputed company has a track record of offering H1B sponsorships, with 10 in 2025, 2 in 2024, 4 in 2023, 5 in 2022, 4 in 2021, 9 in 2020. Please note that this does not guarantee sponsorship for this specific role.

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