Clinical Doc Spclst
Core
Concurrent auditing of medical records to evaluate and improve the quality of clinical documentation, ensuring accurate reflection of severity of illness, expected risk of mortality, and complexity of care.
Role type
Clinical Documentation Specialist (CDI)
Builds
Accurate clinical documentation supporting physician outcomes, facility reporting, and MS-DRG/PR-DRG assignment
Domain
Healthcare / Clinical Documentation Improvement
Required skills
Clinical care and treatment knowledge, PDX/MCC/CC identification, SOI/ROM/risk adjustment analysis, concurrent auditing, query development, physician communication, 3M encoder proficiency, DRG reconciliation, HIM coding standards, regulatory compliance knowledge
Preferred skills
Master's degree, formal education session facilitation
Technologies
3M encoder, CDI Database
Responsibilities
Concurrently audit medical records on admission and throughout hospital stays; Identify gaps in documentation and develop compliant queries; Communicate with physicians and providers to clarify documentation; Provide just-in-time and formal education on documentation requirements; Enter diagnoses and procedure codes to assist with DRG assignment; Perform DRG reconciliation; Maintain CDI Database; Meet established productivity targets for record review.
Seniority
Mid-level, hands-on IC
