Clinical Documentation Improvement Specialist

Essential Responsibilities and Duties

1. Oversees assigned CDI staff to ensure an advanced level review of inpatient medical records to identify gaps in clinical documentation. 

2. Provides advanced level review of inpatient medical records to identify gaps in clinical documentation. Provides guidance to ensure consistency of review of clinical documentation. 

3. Follows up communication with the healthcare providers regarding existing clarifications to obtain needed documentation specification.

 4. Conducts and encourages engagement with healthcare providers in ongoing educational sessions in regards to documentation improvement. Prepares and shares reports on any recurrent gaps, lack of compliance, and findings in the medical records to CDI manager. 

5. Engages medical staff in the process of reviewing clinical documentations for better awareness and smooth knowledge transfer.

 6. Evaluates sub ordinary’s performance and productivity on a monthly basis based on defined KPIs and performs ad-hoc reviews, and counsels them on areas of improvement. 

7. Assists in the development of needed updates of internal policies, procedures and operation manuals for the section. 

Education

Master’s or Bachelor’s Degree in Nursing, Health Information Management or other Healthcare related discipline is required. 

Experience Required

Four (4) years of related experience with Master’s, or six (6) years with Bachelor’sDegree is required.

Other Requirements(Certificates)

? Certified Clinical Documentation Improvement or Health Information Management is preferred

? Experience as an RHIA, CCC, CHIM and/or verifiable documentation review experience gained in a tertiary care setting is preferred.

 ? Certified Medical Coder (AR-DRG) is preferred. 

? Experience with medical insurance is preferred. 

? Deep knowledge of medical documentation.