[Hiring] Clinical Documentation Specialist @Pyramid Consulting

Role Description

Immediate need for a talented Clinical Documentation Specialist - Coding. This is a 06 months contract opportunity with long-term potential and is located in California (Remote).

Key Responsibilities:

• Conduct concurrent medical record reviews within an electronic health record (EHR) environment to ensure accurate and complete documentation.
• Collaborate with physicians and medical coding staff to identify and clarify additional diagnoses impacting severity of illness and risk of mortality indicators.
• Prioritize and manage multiple cases daily to ensure timely and accurate documentation improvements.
• Provide coverage for multiple Northern California facilities as needed based on census and staffing demands.
• Facilitate accurate clinical documentation to reflect the level of service provided to patients.
• Analyze medical records for clinical indicators, symptoms, and diagnoses to identify opportunities for documentation improvement.
• Develop and issue physician documentation clarification queries per coding guidelines and compliance standards.
• Monitor, track, and report the impact of documentation improvement efforts, including query response rates and documentation trends.
• Provide education and feedback to physicians regarding best practices for clinical documentation.
• Conduct data analysis and root cause assessments to support ongoing improvement efforts.
• Collaborate with regional CDI leadership, medical staff, and coding professionals to align documentation practices with clinical and regulatory standards.
• Support policy and procedure development for documentation integrity.
• Participate in special projects, committees, and training programs related to CDI program enhancements.

Qualifications

• Minimum of four (4) years of clinical nursing experience in inpatient care, clinical documentation, discharge planning, or case management.
• Bachelor's degree OR four (4) years of directly related experience in clinical documentation, inpatient care, or case management.
• Strong ability to interpret physician documentation and clinical indicators for documentation enhancement.
• Demonstrated autonomy in decision-making and workflow management.
• Excellent interpersonal and communication skills (verbal and written).
• Ability to conduct and interpret quantitative/qualitative data analysis.
• Leadership skills in project management and consulting.
• Knowledge of adult learning theory and its application in training and orientation.
• Strong time management and organizational skills.
• Ability to work effectively in a Labor/Management Partnership environment.
• Experience working with electronic health records (Epic).
• Experience using 3M Encoder.
• Familiarity with Hierarchical Condition Categories (HCCs).
• Clinical experience in Intensive Care Unit (ICU) settings preferred.
• Minimum of two (2) years of Clinical Documentation Integrity/Improvement experience.
• Minimum of three (3) years of inpatient clinical patient care experience.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.
• Experience in chart review, auditing, utilization management, case management, or discharge planning preferred.
• Knowledge of ICD-CM classification, MS-DRGs, and payment methodologies preferred.
• Advanced degrees such as BSN, MSN, MS (with NP/PA licensure), MBS, or MD preferred.

Requirements

Compensation for this role is subject to periodic review and adjustments. The employer reserves the right to modify job descriptions, compensation structures, and employment classifications as needed. Employees will be notified of any changes impacting their roles.

Benefits

• Pay Range: $45 - $50/hour.
• Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Company Description

Our client is a leading Healthcare Industry, and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.