Clinical Documentation Improvement Specialist

The Clinical Documentation Improvement Specialist facilitates the improvement of the overall quality, completeness, and accuracy of medical record documentation. This role promotes appropriate clinical documentation through extensive interaction with physicians, members of the patient care team, and coding staff to ensure documentation reflects the level of service, severity of illness, and overall accuracy.

Reports directly to the Director of CDI.

Responsibilities

• Concurrently review inpatient admissions to identify opportunities to improve documentation quality.
• Comply with relevant policies, procedures, guidelines, and regulatory, compliance, and accreditation standards.
• Initiate physician interaction to clarify ambiguous or conflicting documentation and ensure clarification is documented according to policy.
• Maintain positive and open communication with physicians, patient care team members, and coding staff.
• Participate in workshops, conferences, and in-services to support professional development.
• Explain the impact of complete documentation on coding quality, DRG assignment, physician profiling, case mix index, and expected mortality rates.
• Stay current with changes in coding guidelines, compliance, reimbursement, and other regulatory updates.
• Understand the flow of health information from medical record documentation and discharge through coding, billing, and data reporting.

Work environment

• Role requires moving about within and outside hospital properties for long periods of time.
• Must be able to respond quickly and effectively to emergency and non-emergent situations.
• May be required to assist in controlling disorderly conduct or combative patients.
• Must be able to exchange accurate information with patients, families, peers, and medical personnel.
• Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.