Clinical Documentation Improvement Specialist
Core
Review clinical documentation for accuracy and severity of illness, query providers for clarification, and educate medical staff on documentation standards to support revenue integrity.
Role type
Clinical Documentation Improvement Specialist (RN)
Builds
Accurate medical records and compliant DRG assignments for inpatient cases
Domain
Healthcare / Revenue Integrity
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
concurrent review of medical records, querying physicians, DRG assignment, Medicare reimbursement knowledge, critical thinking, communication with care providers, data analysis, safety reporting, educational facilitation
Preferred skills
Clinical Coding Specialist (CCS) certification, experience with Epic EHR, knowledge of Blue Cross structures, age-specific disease processes
Technologies
Epic, Excel
Responsibilities
Perform concurrent reviews of admissions to verify documentation accuracy; initiate queries with physicians to clarify diagnoses and procedures; input and reconcile DRG data daily; educate medical staff on documentation requirements; analyze documentation trends to develop improvement plans; generate monthly reports on mortality and case mix.
Seniority
Mid-level, hands-on IC