Role Description - Review and assess clinical documentation for accuracy, completeness, and quality. - Analyze healthcare workflows and recommend process improvements. - Interpret patient records and clinical notes to support product development. - Identify documentation gaps, inconsistencies, and edge cases. - Collaborate with product, engineering, and operations teams to refine AI-driven healthcare tools. - Ensure adherence to healthcare regulations, policies, and best practices. Qualifications - Active Registered Nurse (RN) license. - 3–5+ years of clinical nursing experience. - Strong understanding of clinical documentation and healthcare workflows. - Experience working with EHR systems (Epic, Cerner, Meditech, etc.). - Excellent analytical, communication, and problem-solving skills. - Preferred: Experience in CDI, case management, utilization review, or quality improvement. - Preferred: Exposure to healthcare technology, AI tools, or digital health products. - Preferred: Ability to collaborate effectively with cross-functional teams. Company Description Mercor connects elite creative and technical talent with leading AI research labs. Headquartered in San Francisco, our investors include Benchmark, General Catalyst, Peter Thiel, Adam D'Angelo, Larry Summers, and Jack Dorsey.

Role Description Lead clinical documentation integrity programs for inpatient and outpatient settings. Oversee concurrent and retrospective review workflows. - Evaluate AI-generated clinical documentation improvement suggestions, physician queries, and coding recommendations. - Ensure clinical accuracy and compliance. - Conduct and review clinical documentation. - Ensure accurate capture of diagnoses, procedures, severity of illness, and risk of mortality. - Develop and manage physician query processes. - Align with AHIMA and ACDIS guidelines. - Monitor CDI program KPIs including query response rates, CC/MCC capture rates, case mix index, and DRG accuracy. - Collaborate with coding, compliance, and clinical teams. - Address documentation gaps and improve query processes. Qualifications - 5+ years of experience in clinical documentation integrity or improvement. - At least 2 years in a manager or leadership role. - Deep knowledge of MS-DRG methodology, CC/MCC hierarchies, and ICD-10-CM/PCS coding guidelines. - Expertise in physician query management per AHIMA and ACDIS compliant query standards. - Strong clinical background with the ability to interpret medical records and clinical documentation. - Proficiency with CDI software platforms (3M, Nuance, Optum360, or equivalent) and EHR systems. - Exceptional written and verbal English communication skills. - High attention to detail with the ability to critically evaluate clinical documentation and AI-generated outputs. - Comfortable working independently in a fully remote environment. Requirements - CCDS (Certified Clinical Documentation Specialist) or CDIP (Clinical Documentation Improvement Practitioner) credential preferred. - Experience with HCC risk adjustment and outpatient CDI programs. - Background in RN, RHIA, CCS, or similar clinical or coding credential. - Familiarity with AI-assisted CDI tools (e.g., Nuance DAX, 3M M*Modal) and comfort evaluating AI-generated clinical content. - Experience presenting CDI performance metrics to clinical and executive leadership. Application Process - Upload resume - AI interview based on your resume - Submit form Resources & Support - For details about the interview process and platform information, please check: https://talent.docs.mercor.com/welcome - For any help or support, reach out to: support@mercor.com - Our team reviews applications daily. Please complete your AI interview and application steps to be considered for this opportunity.

Role Description Performs concurrent analytical reviews of clinical and coding data to improve physician documentation for all conditions and treatments from point of entry to discharge, ensuring an accurate reflection of the patient condition in the associated Diagnosis Related Group (DRG) assignments, case-mix index, severity of illness (SOI), and risk of mortality (ROM) profiling, and reimbursement. Facilitates the resolution of queries and educates members of the patient care team regarding documentation guidelines and the need for accurate and complete documentation in the health record, including attending physicians and allied health practitioners. Collaborates with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, SOI, and/or ROM. Qualifications - Graduate of accredited school of nursing, PA, NP, or medical school, or Associate's degree and Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialist (ACDIS) - Two years' experience in an acute care setting or relevant experience Requirements - Completes initial reviews of patient records and evaluates documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate diagnosis review group (DRG) assignment, risk of mortality (ROM), and severity of illness (SOI). - Maintains appropriate productivity level. - Conducts follow-up reviews of patients to support and assign a working or final DRG assignment upon patient discharge, as necessary. - Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed. - Identifies issues with reporting of diagnostic testing proactively. - Enhances expertise in query development, presentation, and standards including understanding of published query guidelines and practice expectations for compliance. - Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record. - Attends department meetings to review documentation related issues. - Conducts independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics. - Collaborates with coding to reconcile the DRG and resolves mismatches utilizing the escalation policy. - Troubleshoots documentation or communication problems proactively and appropriately escalates. - Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, SOI, and/or ROM. - Assists in the mortality review and risk adjustment process utilizing third-party models. - Demonstrates an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record. - Imparts knowledge to providers and other members of the healthcare team. - Maintains a level of expertise by attending continuing education programs. - Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's scope of service. - Works in a constant state of alertness and safe manner. - Performs other duties as assigned. Benefits - Paid Parental Leave: one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE). - Flexible Payment Options: instant access to earned, unpaid base pay for eligible hourly team members (fees may apply) before payday. - Upfront Tuition Coverage: upfront tuition coverage through FlexPath Funded for eligible team members.

• Review inpatient medical records to ensure completeness and accuracy for severity of illness and risk of mortality. • Ensure effective communication with healthcare staff to suggest additional documentation. • Work closely with HIM coding staff to confirm discharge diagnoses and co-morbidities are accurately reflected. • Conduct concurrent review of medical records and document findings on CDS worksheets. • Identify principal and secondary diagnoses, procedures, and quality indicators. • Clarify documentation as needed and facilitate accurate patient records. • Use monitoring tools to track program progress and share findings. • Educate staff on documentation improvement and facilitate compliance. • Engage with healthcare team to improve clinical documentation processes.