Clinical Document Improvement Specialist

About Trilyon, Inc.

With over 16 years of experience, Trilyon, Inc. delivers extensive global workforce solutions and staffing services. They expertly support diverse sectors including Cloud technology, Salesforce, AI, Machine Learning, and Technical Writing to consistently meet varied client needs.

Position Overview

The Clinical Document Improvement Specialist (CDS) role is a remote contract position lasting over six months. This role requires applying clinical knowledge to meticulously examine medical records to ensure documentation accurately portrays illness severity and care quality.

Key Responsibilities

• Perform concurrent medical records review to validate comprehensive and precise documentation.
• Collaborate closely with physicians and other healthcare providers to clarify and improve medical records.
• Ensure documentation complies with MS-DRG classification guidelines and CMS regulations.

Qualifications and Experience

• Must hold a medical degree as an International Medical Graduate (IMG) or possess an RN license.
• At least 2 to 3 years of experience working as a Clinical Documentation Specialist.
• Preferred clinical specialties include Obstetrics and Gynecology (OBGYN), Pediatrics, and Inpatient Psychiatry.
• Demonstrated experience in quality assurance reviews, mortality reviews, and use of risk adjustment tools.
• Certification requirements include CCDS or CCDIP credentials.

Desired Skills and Attributes

• Strong communication capabilities to effectively engage in a virtual team setting.
• Ability to work independently within a remote team environment.