Compliance Documentation Improvement Specialist
Core
Reviews inpatient medical records to identify diagnoses and assign MS-DRGs based on clinical evidence to support corporate compliance and quality goals.
Role type
Clinical Documentation Improvement Specialist
Builds
Accurate severity-based DRG assignments and improved medical record documentation
Domain
Healthcare administration / Clinical coding
Required skills
MS-DRG system knowledge, medical record review, physician interaction, conflict resolution, disease process knowledge, compliance policy enforcement
Preferred skills
Case management experience, financial and analytical skills, clinical experience in assigned population
Technologies
Licensed medical record review software, Microsoft Word, Outlook, Excel
Responsibilities
Review inpatient medical records to identify principal and secondary diagnoses; Assign MS-DRGs reflecting patient severity of illness; Clarify vague or incomplete documentation with physicians; Collaborate with coding, compliance, quality, and finance departments; Educate healthcare team members on documentation improvement; Ensure written documentation requests align with corporate compliance policies
Seniority
Mid-level, hands-on specialist