Clinical Documentation Improvement Specialist
Core
Reviews inpatient medical records to improve quality, completeness, and clinical severity of documentation for DRG/APR payor populations.
Role type
Clinical Documentation Improvement Specialist (RN)
Builds
Accurate clinical documentation and reimbursement data for hospital departments
Domain
Healthcare / Revenue Cycle Management
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure | physical/clinical work
Required skills
Acute care nursing experience, Utilization review, Case management, Quality management, DRG assignment, Comorbidity identification, Present on admission diagnosis identification, Epic EHR proficiency, 3M 360 software proficiency, Clinical query development, Risk management reporting (PSI/HAC)
Preferred skills
Hospital-based clinical documentation experience, Healthcare revenue cycle experience
Technologies
Epic, 3M 360, Microsoft Office Suite
Responsibilities
Review inpatient charts within 24-48 hours to ensure accuracy and completeness; Assign working DRGs and identify comorbidities/complications; Communicate documentation opportunities to physicians and care providers; Develop and present educational materials on documentation; Act as subject matter expert for CDI department; Manage CDI tracking tools and database for reimbursement reporting; Participate in internal institutional committees.
Seniority
Mid-level, hands-on IC