Clinical Documentation Improvement Specialist

Job Summary

To ensure accurate clinical documentation and coding, the full-time Clinical Documentation Improvement Specialist will conduct comprehensive chart reviews, collaborate with healthcare professionals, and initiate physician queries while working remotely.

Key responsibilities

• Perform thorough secondary clinical chart reviews to identify documentation improvement opportunities
• Conduct daily concurrent reviews of inpatient records to ensure accurate documentation at discharge
• Initiate compliant physician queries to clarify confusing or ambiguous documentation

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
• 2+ years of prior Clinical Documentation Improvement experience
• Familiarity with encoder and DRG assignment