Clinical Documentation Specialist
New
Based in the United StatesFull-TimeMiddle
Salary$61,000 – $101,000
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Job Details
- Experience
- 4+ years of experience providing direct patient care in inpatient settings; 2+ years of prior Clinical Documentation Improvement (CDI) experience.
- Required Skills
- EHR
Requirements
- Bachelor’s degree.
- Active professional qualification as an RN, MD, or equivalent medical degree (MBBS).
- 4+ years of experience providing direct patient care in inpatient settings (e.g., acute care, critical care, ED, or medical-surgical).
- 2+ years of prior Clinical Documentation Improvement (CDI) experience.
- Familiarity with encoder tools, DRG assignment processes, and clinical coding methodologies.
- Strong knowledge of official coding guidelines, coding clinics, medical terminology, anatomy, physiology, microbiology, and disease processes.
- Experience with EHR systems, CDI software platforms, and coding technologies.
- Strong critical thinking, analytical abilities, and problem-solving skills.
- Excellent interpersonal and communication skills.
- CCDS or CDIP certification (preferred).
Responsibilities
- Perform daily concurrent reviews of inpatient medical records to identify opportunities for documentation clarification and improvement.
- Evaluate clinical documentation to ensure it accurately represents patient conditions, severity of illness, and risk of mortality.
- Collaborate with physicians, coders, coding educators, auditors, case managers, and quality teams to improve documentation practices.
- Conduct initial reviews of patient admissions, assign working DRGs, and maintain accurate CDI software documentation.
- Update working DRG assignments based on supporting clinical documentation and physician query responses.
- Initiate compliant physician queries when documentation is incomplete, unclear, conflicting, or requires clarification.
- Follow established clinical documentation improvement guidelines and regulatory standards to maintain compliance.
- Communicate workload needs and review volume concerns to support efficient assignment management across the CDI team.
- Utilize electronic health record systems, CDI platforms, and coding tools to support effective documentation review processes.
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