Virtua Health seeks a full-time Clinical Documentation Improvement (CDI) Specialist, requiring current RN licensure. The role is 100% remote for candidates in specified US states. Virtua is a Magnet-recognized health system known for quality, safety, and community care, affiliated with Penn Medicine and Children's Hospital of Philadelphia. The CDI Specialist evaluates and analyzes medical records concurrently to ensure accurate documentation supporting diagnoses and treatment. The specialist collaborates with HIM coders, clinicians, physicians, and various hospital leaders to improve documentation quality and implement performance improvement activities using DMAIC cycles. The position requires 2 years of hospital clinical experience, proficiency in Microsoft Office tools, analytical skills, and effective communication abilities. Coding knowledge (ICD-9-CM and AHA Coding Clinic) is preferred. The role includes review of admissions, ongoing re-reviews until discharge, data trending, physician querying, and education efforts.

Evaluate and analyze medical records concurrently for proper documentation, including new admissions and ongoing reviews until discharge. Manage and trend data collection for assigned hospital/facility/specialty. Verify diagnoses for proper DRG coding; query physicians for further documentation when necessary. Collaborate with HIM coders, clinicians, physicians to ensure documentation accuracy and timeliness. Provide training and education to clinicians and physicians through meetings and performance reviews. Work with Quality and Case Management teams to address documentation issues and develop action plans. Assist hospital leadership in documentation improvement preparation and response. Review documentation fallouts with physicians and relevant departments. Implement performance improvement activities per Virtua Quality Plan. Educate and coach staff and physicians on DMAIC cycles.