Clinical Documentation Improvement Specialist - Clinical Document Improvement - Full Time 8 Hours Days (7:00AM to 5:30PM) (Non-Union, Non-Exempt)
Core
Reviewing inpatient medical records to improve the specificity and completeness of physician clinical documentation for accurate severity of illness representation and regulatory compliance.
Role type
Clinical Documentation Improvement (CDI) Specialist
Builds
Improved medical record documentation quality and accurate coding for hospital reimbursement
Domain
Healthcare / Clinical Documentation / Medical Coding
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
ICD-10 CM/PCS coding, medical record review, clinical querying, pathophysiology knowledge, Medicare Part A/DRG assignment rules, anatomy/physiology understanding
Preferred skills
CCS/CCA/CDIP/CCDS certification, CPT/HCPCS coding, AHA Coding Clinic knowledge, utilization review experience
Technologies
Windows based software programs
Responsibilities
Review inpatient medical records for identified payor populations; Identify gaps in physician documentation regarding clinical status and treatment plans; Collaborate with coding staff to ensure complete reflection of patient care; Develop educational plans for clinical staff; Design tools to support physician documentation; Respond to coding denials with clinical justifications
Seniority
Mid-level, hands-on IC