Clinical Documentation Specialist
Core
Conducts daily concurrent reviews of inpatient clinical charts to identify missed documentation opportunities, ensure accurate severity of illness coding, and initiate compliant physician queries.
Role type
Clinical Documentation Improvement (CDI) Specialist
Builds
Accurate DRG assignments and compliant coding data for inpatient units
Domain
Healthcare / Medical Coding & Documentation
Required skills
Clinical patient care experience, CDI program experience, physician query management, DRG assignment, medical terminology, anatomy, physiology, disease processes, EHR systems proficiency
Preferred skills
CCDS or CDIP certification, ED or critical care experience, case management experience, coding or utilization review experience, strong critical thinking
Technologies
EHR systems, CDI software systems, encoders
Responsibilities
Review daily admissions and inpatient records for documentation completeness, perform initial code assignment and DRG updates, initiate and follow up on physician queries, collaborate with coders and quality auditors, adjust review volume with coordinator
Seniority
Mid-level, hands-on IC
