Senior Consultant - Clinical Documentation Specialist

About the role

The Deloitte Regulatory, Risk & Forensic team assists clients in translating multifaceted risk and an evolving regulatory environment into actionable strategies that enhance their organizational resilience and performance.

Responsibilities

• Analyze medical records for inpatient and outpatient service areas for accuracy of coding and documentation to ensure regulatory compliance.
• Evaluate clinical documents for accuracy of medical terminology, disease conditions, and procedures.
• Maintain oversight of diagnoses, treatments, and follow-up entries in medical records to ensure coding accuracy.
• Identify gaps in clinical documentation and request missing information from relevant providers.
• Develop and implement educational plans for physicians, CDI team, health information management, and other clinical staff.
• Create and deliver presentations at local and national conferences and client meetings.
• Manage and prioritize multiple tasks in a fast-paced and dynamic environment.
• Provide clear guidance to others and participate in executive meetings to discuss CDI benchmarks, KPIs, and program accomplishments.

Requirements

• Bachelor's degree in nursing, medical degree, or physician assistant required.
• Current Registered Nurse (RN) license required.
• Certified Clinical Documentation Specialist - CCDS (inpatient) certification required.
• A minimum of 3 years of experience in acute inpatient settings.
• Extensive experience in collecting, interpreting, and communicating medical information to select appropriate clients with recommendations and plan of action.
• Knowledge of care delivery documentation systems and related medical record documents.
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
• Strong analytical skills.
• Ability to keep up to date with advancements and regulations in medical coding and clinical documentation.
• Proficient in MS Word, Excel, and PowerPoint.
• Proficient in Electronic Medical Record (EMR) software, such as Epic, Cerner, Allscripts, etc.
• Excellent verbal and written communication skills with small and large group presentation skills.
• Ability to work independently and with multiple teams in a time-sensitive environment.
• Must be legally authorized to work in the United States without the need for employer sponsorship, now or in the future.

Qualifications

• Master's degree in Clinical Informatics, Business Administration, Nursing and related health fields preferred.
• Case Management or Medical coding certification a plus (CRC, CCA, CCS-P, CCS, CPC, CDIP, CCM).
• Experience as clinical registered nurse, physician, physician assistant, case manager, clinical documentation specialist, utilization review, informatics RN, Quality, DRG Validation and health IT preferred.
• Knowledge of Medicare reimbursement system and coding structures preferred.
• In-depth knowledge and experience in medical terminology, medical coding, and ICD-10-CM/PCS, IPPS payment system is a plus.
• Experience in quality measurement, quality improvement, and value-based payment models.
• Proven applicable CPT and ICD-10 coding experience; APR-DRG, MS-DRG and HCC assignment.
• Experience in program and/or project management for technology implementations using third party software.
• Experience in process excellence (Six Sigma, LEAN, Design Excellence), certifications preferred.