Support accurate, complete clinical documentation by reviewing patient records, identifying documentation gaps, and querying providers to clarify diagnoses and care delivery. This role focuses on concurrent and retrospective chart review, severity of illness and risk of mortality capture, and documentation quality across the chart. The work is remote after onboarding and involves close collaboration with providers, coders, and clinical teams.
Key Responsibilities
- Review clinical documentation for accuracy, completeness, and compliance.
- Identify documentation gaps and support clarification through provider queries.
- Perform concurrent and retrospective chart reviews.
- Support accurate capture of severity of illness (SOI) and risk of mortality (ROM).
- Collaborate with providers, coders, and clinical teams to improve documentation quality.
Required
- Background as an RN or Physician (MD/MBBS).
- Experience in Clinical Documentation Improvement (CDI).
- Strong understanding of clinical documentation and coding principles, including ICD-10 and DRG.
- Ability to work independently and communicate effectively with providers.
Preferred
- Experience in outpatient, ambulatory, or risk adjustment (HCC) documentation.
- CDIP, CCDS, CRC, or similar certification.
- Experience with Epic or other EHR systems.
Benefits & Perks
- Remote work after initial onboarding.
- Contract role with an estimated length of 6-7 months.
- Standard business hours.