Clinical Documentation Improvement Specialist

Job Summary

Working remotely in a full-time capacity, the Clinical Documentation Improvement Specialist will conduct comprehensive clinical chart reviews to identify documentation opportunities, collaborate with healthcare teams, and ensure compliance with coding standards.

Key responsibilities

• Perform daily, concurrent reviews of inpatient records to ensure accurate physician documentation at discharge
• Initiate compliant physician queries for ambiguous or missing documentation and follow up for timely responses
• Collaborate with coding and quality teams to maintain documentation that reflects the severity of illness and risk of mortality

Required qualifications

• Bachelor's degree
• One of the following: RN, MD, or MD Equivalent (MBBS)
• 4+ years of direct patient care experience in inpatient settings, critical care, or strong med-surg experience
• 2+ years of prior Clinical Documentation Improvement experience
• Familiarity with encoder and DRG assignment, along with current knowledge of official coding guidelines