Opportunity Description
The Clinical Documentation Improvement Specialist focuses on the accuracy, completeness and consistency of inpatient clinical documentation to support coding and reporting of high-quality healthcare data. The Specialist performs concurrent chart reviews to validate that the clinical documentation in the medical record appropriately describes the patient’s severity of illness, complexity of care, and risk of mortality to facilitate appropriate coding. The Specialist utilizes advanced knowledge of disease processes, medications, and critical thinking to analyze current documentation, identify gaps, and facilitate appropriate modifications through extensive interactions and collaboration with providers, coding, quality, and case management teams, serving as an effective change agent and educator for providers and interdisciplinary care teams.
Key Responsibilities
Reviewing Patient Records
- Analyzing medical records to identify incomplete or inaccurat...