Clinical Documentation Improvement Specialist

Job Summary

Collaborating with healthcare professionals, the full-time Clinical Documentation Improvement Specialist will conduct comprehensive chart reviews, ensuring accurate documentation and compliance with regulatory standards while working remotely.

Key responsibilities

• Perform daily concurrent reviews of inpatient records to ensure complete and accurate documentation
• Initiate compliant physician queries for ambiguous or missing documentation and follow up for timely responses
• Update working DRG assignments based on documentation and communicate with the CDI Coordinator regarding review assignment volumes

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, along with current coding guidelines