Clinical Documentation Improvement Specialist
New
Based in the United StatesFull-TimeMiddle
Salary48,131 - 81,225.49 USD per year
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Job Details
- Experience
- Three to five years of recent clinical experience in medical-surgical, intensive care, telemetry, emergency department, or related acute care settings
- Required Skills
- Microsoft OfficeCritical thinking
Requirements
- Associate Degree in Nursing required; Bachelor of Science in Nursing (BSN) preferred.
- Active and unrestricted U.S. Registered Nurse (RN) license required.
- Three to five years of recent clinical experience in medical-surgical, intensive care, telemetry, emergency department, or related acute care settings.
- Strong knowledge of clinical documentation improvement practices, coding methodologies, reimbursement structures, and healthcare quality measures.
- Experience working with electronic medical record (EMR) systems and CDI technology platforms.
- Understanding of CMS regulations, coding guidelines, compliance standards, and healthcare documentation requirements.
- Excellent critical thinking, analytical, and problem-solving skills with the ability to evaluate complex clinical scenarios.
- Strong written and verbal communication skills with the ability to effectively educate providers and clinical teams.
- Ability to work independently, manage multiple priorities, and thrive in a fast-paced healthcare environment.
- Proficiency with Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook.
- Strong interpersonal skills, professional judgment, adaptability, and commitment to continuous learning.
Responsibilities
- Conduct concurrent and retrospective reviews of inpatient medical records to identify opportunities for documentation improvement and coding accuracy.
- Initiate physician queries and collaborate with providers to clarify ambiguous, incomplete, or conflicting documentation to support accurate coding and clinical representation.
- Facilitate documentation that appropriately reflects severity of illness, risk of mortality, complexity of care, case mix index (CMI), length of stay (LOS), and resource utilization.
- Educate physicians, clinical staff, and stakeholders on documentation standards, coding guidelines, reimbursement requirements, and regulatory expectations.
- Apply coding principles, reimbursement guidelines, and documentation standards to support accurate working DRG assignments and clinical documentation integrity.
- Collaborate with coding teams, auditors, quality improvement professionals, and other stakeholders to resolve documentation issues and improve data quality.
- Conduct focused reviews related to mortality, patient safety indicators (PSIs), and other quality or compliance initiatives identified by leadership.
- Monitor evolving documentation, coding, and regulatory requirements to ensure ongoing compliance and best practices.
- Assist with onboarding, training, and mentoring new CDI team members.
- Contribute to continuous improvement initiatives aimed at enhancing documentation quality, reporting accuracy, and operational effectiveness.
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