Under the direction of the Site Manager of the Clinical Documentation Integrity (CDI) program, the Clinical Documentation Specialist supports accurate and complete inpatient medical record documentation to ensure precise ICD-10-CM and ICD-10-PCS coding and high-quality healthcare data.
Key responsibilities include:
- Performing concurrent and retrospective chart reviews to support accurate APR-DRG, severity of illness (SOI), and risk of mortality (ROM) assignment.
- Identifying documentation gaps and collaborating with providers through verbal or written queries in accordance with organizational and AHIMA standards.
- Supporting complete documentation of diagnoses, procedures, present-on-admission status, comorbidities, and clinical significance.
- Educating providers and clinical teams on documentation improvement opportunities and supporting ongoing CDI initiatives.
- Serving as a liaison between HIM/coding staff and providers to reconcile diagnostic and procedural data and validate final coded outcomes.
- Maintaining continuing education to stay current on CDI standards and credentialing requirements.
Requirements & Qualifications
- Associate’s degree
- Active licensure as an RN, MD, PA, or CRNP
- At least 2 years of experience reviewing inpatient medical records as a Clinical Documentation Integrity Specialist, Coder/DRG Analyst, Care Manager, Utilization Review Specialist, or Quality Review Specialist
- Or at least 3 years of chart abstraction/chart review experience
- Must obtain CCDS or CDIP certification within 2 years of hire or eligibility
- Preferred at hire: CCDS or CDIP
- Preferred additional credentials: CCS, RHIT, or RHIA
Location
Baltimore, Maryland, US
Employment Type
Full-time
Experience Level
Associate
Remote work allowed
No
Posted
2 months ago