Medical Coding Modernization Specialist, CDI & Clinical Documentation
Overview
You will own the clinical documentation improvement program at Walter Reed Military Medical Center, driving accurate coding, Severity of Illness (SOI) and Risk of Mortality (ROM) capture for a high-acuity inpatient population. You will collaborate with physicians, coders, and case managers to clarify diagnoses and procedures, using CDI software and DHA compliance standards. This role offers direct impact on quality metrics, reimbursement, and patient safety. You will also shape provider education and lead performance improvement initiatives in a mission-driven federal healthcare environment.
What You'll Do10
- 1Review inpatient medical records daily, concurrent with patient stay, to identify missing or incomplete documentation.
- 2Collaborate with physicians, case managers, coders, and other care team members to clarify diagnoses, treatments, and interventions.
- 3Use the designated CDI software to conduct record reviews and track query opportunities.
- 4Follow up on posted queries to ensure provider responses within the 72-hour DHA compliance window.
- 5Lead education sessions on ICD-10 coding, compliance, and documentation best practices, including rounding with multidisciplinary teams.
- 6Consult with HIM coding professionals on complex cases to ensure accurate final coded data.
- 7Develop provider education strategies to reverse negative documentation trends and improve query clarity.
- 8Prepare physician-specific performance data and report metrics to medical staff and committees.
- 9Support denials management by analyzing documentation and coding for appealed cases.
- 10Compile monthly activity logs and outcome summaries for PAD leadership.
Requirements7
- 15+ years experience as a Clinical Documentation Improvement Specialist in a critical care environment.
- 2Hold current CDIP or CCDS certification.
- 3Experience with criteria-based chart review in utilization management, case management, or quality improvement.
- 4Strong written and verbal communication skills, with highly developed organizational and analytical abilities.
- 5Proven ability to build collaborative relationships with physicians, residents, mid-level clinicians, and coders.
- 6Knowledge of healthcare coding regulations and documentation requirements, including ICD-10 and MS-DRG.
- 7Ability to work on-site at Walter Reed Military Medical Center, 5 days per week, during core PAD hours.
Salary Insight
$71 - $77k per year
Location
Required Skills
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