Clinical Documentation Improvement Specialist

Job Summary

Working remotely in a full-time capacity, the Clinical Documentation Improvement Specialist will conduct comprehensive secondary clinical chart reviews, collaborate with healthcare teams to ensure accurate documentation, and initiate physician queries to clarify ambiguous records.

Key responsibilities

• Perform daily, concurrent reviews of inpatient records to ensure complete and accurate documentation at discharge
• Conduct initial code assignments and maintain DRG assignments based on updated documentation
• Communicate with the CDI Coordinator regarding review assignment volumes and initiate compliant physician queries as needed

Required qualifications

• Bachelor's degree
• One of the following: RN, MD, or MD Equivalent (MBBS)
• 4+ years of experience in direct patient care in inpatient settings
• 2+ years of prior Clinical Documentation Improvement experience
• Familiarity with encoder and DRG assignment