Position: Clinical Documentation Medical Professional (Remote)
Duration: Initial 3-month contract with possibility to extend/convert
Shift: M-F, Standard Hours
Rate: Up to $41.50 an hour
Location: Remote
Proof of Education at Time of Submission: Foreign or domestic Medical School Graduate (license not required), OR Graduate from a Physician’s Assistant or RN Program. Minimum 3 years’ experience. Fill out the non-clinical submission coversheet attached in BH.

SUMMARY

The Clinical Documentation Medical Professional (CDMP) is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDMP will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDMP will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, patient caregivers, and health information management coding staff to ensure that reimbursement (reflecting proper quality of care and appropriate reimbursement) is received for the level of services rendered to the patients.

REQUIREMENTS

• Foreign or domestic Medical School Graduate (license not required), OR Graduate from a Physician’s Assistant or RN Program.
• Graduate from a Registered Nurse Practitioner program preferred.
• Minimum 3 years of experience in the area of population to be served is required.
• Three (3) years previous acute hospital inpatient coding experience highly preferred.
• M.D. or D.O.; ECFMG certification (preferred for Foreign Medical Graduates).
• RN or Current PA or RNP license required, as appropriate.
• Certified Clinical Documentation Specialist (CCDS) highly preferred.
  Job Types: Full-time, Contract
  Pay: $33.89 - $40.50 per hour
  Expected hours: 40 per week

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Vision insurance

Work Location: Remot

• Perform concurrent and retrospective reviews of the medical record utilizing practice experience, evidence-based knowledge, protocols, and criteria.
• Work closely with the medical staff and other healthcare team members to identify potential gaps in physician documentation and ensure appropriate reimbursement for the level of service rendered.
• Utilize research, analytic data, observations, and practice experience to provide recommendations to improve overall quality and completeness of clinical documentation.
• Establish cooperative and multidisciplinary relationships with physicians, coding staff, and other health team members.
• Act as a resource to the CDI department and health team members related to optimal documentation, educational needs, and problem resolution.
• Demonstrate familiarity with MS-DRG/APR-DRG’s and Inpatient Prospective Payment System (IPPS).
• Complete initial reviews of patient records to evaluate documentation and assign principal and secondary diagnoses and procedures for accurate DRG, risk of mortality, and severity of illness assignment.
• Complete follow-up reviews and review a minimum standard of charts per day as directed.
• Analyze clinical information and formulate appropriate clinical documentation clarifications.
• Query and educate physicians and key healthcare providers regarding clinical documentation improvement.
• Track responses to documentation and monitor trends in CDI metrics.
• Maintain and enhance current medical, coding, and CDI knowledge through continuing education and CMEs.
• Consistently meet established productivity targets for record review.
• Assist in collection and organization of data for analysis by medical and hospital committees.
• Ensure compliance with all policies, procedures, and standards set by state and federal agencies, the hospital, and other regulatory entities.
• Protect patient confidentiality at all times.
• Perform other duties as assigned.