Clinical Documentation Specialist

Job Summary

A company is looking for a Clinical Documentation Specialist I to provide education and ensure accurate documentation of clinical conditions and procedures.

Key Responsibilities

• Review medical records to determine diagnoses and procedures, ensuring accurate DRG assignment
• Query and educate providers for precise documentation and compliance with industry standards
• Maintain records of review and query activities within the CDI software system

Required Qualifications

• High School Diploma/GED or equivalent
• Five years of experience as a clinical nurse or coder, or two years as a Clinical Documentation Integrity Specialist
• Certified Clinical Documentation Specialist (CCDS or CCDS-O) from ACDIS, obtained within 1 year of hire
• Proficient in department CDI software and reporting functions
• Physical ability to perform job tasks, including lifting and manual dexterity