Clinical Documentation Improvement Specialist

Job Summary

To enhance clinical documentation accuracy, the fully remote Clinical Documentation Improvement Specialist will communicate with healthcare teams to clarify medical record documentation, ensuring appropriate severity of illness and complexity of care while performing in-depth chart reviews.

Key responsibilities:

• Collaborate with healthcare teams to identify and resolve missing or unclear documentation
• Conduct comprehensive chart reviews to support accurate coding and quality metrics
• Complete extensive training modules and one-on-one sessions with a CDI trainer

Required qualifications:

• Minimum of two years' experience in an acute care hospital setting
• Background in critical care, general medical, or surgical nursing
• Experience with criteria-based chart reviews, such as case management or quality improvement
• Knowledge of ICD code assignment and DRG assignment preferred
• Experience in educational presentations is beneficial