Clinical Documentation Improvement Specialist

Clinical Documentation Improvement Specialist

Supports and reviews the inpatient medical record in order to facilitate improvement in overall quality, completeness, clinical severity, and accuracy of inpatient clinical documentation for DRG based or APR based payor population for specific departments or areas. Obtains and promotes appropriate clinical documentation through extensive interaction with physicians and other members of the healthcare team.

Education and Experience Required:

Three (3) years of clinical nursing experience in Acute Care, Utilization Review, Case Management, and/or Quality Management.

Certifications, Licenses, or Registration required:

Valid RN license, CCDS (Certified Clinical Documentation Specialist)

Preferred Qualifications:

Three (3) years of related hospital-based clinical documentation experience

Knowledge, Skills, and Abilities:

Demonstrates knowledge of evidence-based clinical guidelines across diverse conditions and age groups, as well as resource and utilization management, cost, and quality issues. Skilled in the use of personal computers and Microsoft Office Suite (Excel, PowerPoint, Word, Outlook) and other related software applications. Able to manage multiple priorities under time constraints, analyze problems, and make sound decisions. Possesses excellent verbal and written communication skills and strong interpersonal abilities to collaborate effectively across departments and business units, fostering a team-oriented environment. Healthcare revenue cycle experience is preferred.

Responsibilities:

• Highly skilled authority regarding accuracy of reviewing inpatient charts within 24-48 hours of admission to ensure accuracy and completeness and identifies documentation opportunities that reflect severity of illness, acuity, and resource consumption. Assigns a working DRG based on principal diagnosis and procedure. Identifies comorbidities and complications. Accurately identifies present on admission diagnoses. Identifies quality issues and reports to the responsible party. Has advanced decision-making capabilities a with high developed degree of accuracy.
• Reviews and enters information in both epic and 3m 360 as required. Has advanced abilities in using these software systems.
• Highly skilled authority regarding accuracy of reviewing inpatient charts every 24-48 hours as a follow up. Identifies documentation that reflects the severity, acuity, quality issues and resource consumption and updates his/her findings in 3m 360 software. Accomplished in quality and production.
• Skillfully communicates with physicians and other patient care providers, both verbally and written in a clear and concise way, regarding documentation opportunities for improvement. Assists in development and presentation of educational materials regarding documentation for both cdi staff and/or providers and other members of the healthcare team.
• Demonstrates competent and effective assessment skills to identify clinical indicators for diagnoses. Integrates new or current techniques (of procedures or surgery, cdi issues, opportunities for documentation improvement) to obtain information as it relates to the planning, implementing, and evaluating of patient care documentation.
• Serves as subject matter expert and actively participates in the cdi department as a problem solver. Trends issues with denials for team education. Expertise in query development, guidelines, and standards.
• Serves as a cdi department liaison for providers and administrative meetings
• Serves as a database manager for cdi tracking tools, including DRG validation and reconciliation for accurate and timely reporting of cdi generated reimbursement, case index and production improvement. Gathers and analyzes information pertinent to documentation findings and outcomes.
• Serves on internal institutional committees as requested by management
• Must maintain a current ACDIS certification status. Participates in cdi-related continuing education activities to maintain certifications and licensures.
• Ability to formulate a more complex query in order to obtain clarifications of conflicting, ambiguous, or non-specific documentation, by verbal or written compliant queries. Ability to determine when it is appropriate to escalate an issue to senior team member, provider, or administrator.
• Has a highly developed understanding of what constitutes a risk management and/or quality program reporting (patient safety indicators-psi/hospital-acquired conditions-hac or mortality) cases. Aids other team members in identification and proper classification of complication codes, patient safety indicators/hospital-acquired conditions by acting as an intermediary between him/coding staff and medical staff.
• Expert understanding of what constitutes a risk management and/or quality program (PSI/HAC) case, and discusses with management, as appropriate.
• Works independently but collaborates appropriately with cdi management and him/coding management to review individual problematic cases and/or educational needs, as needed.
• Conducts independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics.
• The duties listed are general in nature and are examples of the duties and responsibilities performed and are not meant to be construed as exclusive or all-inclusive. Management retains the right to add or change duties at any time.

Physical and Environmental Demands:

Requires no exposure to unpleasant or disagreeable physical environment such as high noise level and exposure to heat and cold, no handling or working with potentially dangerous equipment, occasional working hours beyond regularly scheduled hours, occasional travelling to offsite locations, frequent activities subject to significant volume changes of a seasonal/clinical nature, constant work produced is subject to precise measures of quantity and quality, occasional bending, occasional lifting/carrying up to 10 pounds, occasional lifting/carrying up to 25 pounds, no lifting/carrying up to 50 pounds, no lifting/carrying up to 75 pounds, no lifting/carrying up to100 pounds, no lifting/carrying 100 pounds or more, occasional climbing, no crawling, occasional crouching/stooping, occasional driving, no kneeling, occasional pushing/pulling, frequent reaching, frequent sitting, frequent standing, occasional twisting, and frequent walking (occasional-up to 20%, frequent-from 21% to 50%, constant-51% or more).

Time Type: Full time

FLSA Designation/Job Exempt: No

Pay Class: Hourly

FTE %: 100

Work Shift: Day

Benefits Eligibility: Grant Funded: No

Job Posting Date: 03/18/2026

Job Closing Date (open until filled if no date specified):