Berkeley Research Group (BRG) logo
Berkeley Research Group (BRG)

Intelligence that works.

Healthcare Clinical Documentation Integrity Consultant

Medical writerMedical writerFull TimeRemoteSeniorTeam 1,001-5,000H1B No SponsorCompany SiteLinkedIn

Location

New York

Posted

96 days ago

Salary

$70K - $150K / year

Seniority

Senior

Bachelor Degree4 yrs expEnglish

Job Description

• Review inpatient medical records for identified payer populations on admission and throughout hospitalization. • Analyze clinical information to identify areas within the chart for potential gaps in physician documentation. • Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality measures, and patient safety indicators (PSI). • Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses, and ancillary staff. • Work collaboratively with the coding staff to assure documentation of discharge diagnoses and comorbidities are a complete reflection of the patient’s clinical status and care. • Develop and implement plans for education of physician, nursing, and ancillary staff on documentation improvement.

Job Requirements

  • 4-7 years of experience as a Clinical Documentation Improvement (CDI) Specialist within a hospital setting or as a CDI consultant, or a combination thereof.
  • RN, BSN, or Health Information Management degree required.
  • Currently licensed as a Registered Nurse – ICU, OR, ED specialty preferred, with a strong understanding of clinical workflow.
  • Minimum 2 years of inpatient coding experience with ICD-10 CM/PCS preferred.
  • ACDIS or AHIMA certification preferred.
  • Strong knowledge of CDI principles, including the ability to audit medical records, teach CDI principles to clinicians, coders, and other healthcare professionals.
  • Experience in clinical documentation improvement, coding, audit, or Health Information Management.
  • Ability to assist with the development of CDI and HIM training and consulting tools and methodologies.
  • Excellent organizational, analytical, and writing skills, with the ability to demonstrate critical thinking and problem-solving.
  • Strong verbal and written communication skills, with excellent public speaking and presentation abilities.
  • Effective communication with physicians, coding professionals, and other stakeholders.
  • Knowledge of regulatory guidelines and Medicare Part A, MS-DRG, and/or APR-DRG payment methodologies.
  • Ability to pass a written clinical competency assessment.
  • Familiarity with hospital systems such as EPIC, MEDITECH, or similar platforms is desired.
  • Strong proficiency in MS Office applications, including Word, PowerPoint, Excel, and Outlook.
  • Excellent time management skills and the ability to handle multiple priorities effectively.

Benefits

  • Competitive sign-on bonus to welcome exceptional talent.

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