Clinical Documentation Improvement Specialist

Job Description

Job Description

Responsible for performing concurrent reviews of patient records to ensure complete, accurate, and specific clinical documentation. Should have a comprehensive understanding of ICD and CPT Coding Guidelines and are responsible for clarifying conflicting, incomplete, or imprecise documentation by actively seeking answers and actively educating providers.

Work to continuously improve clinical documentation to best reflect the care provided and corresponding reimbursement. Responsible for improving the overall quality and completeness of clinical documentation. Facilitate modifications to clinical documentation through extensive concurrent interaction with physicians, nursing staff, other patient caregivers, and Coding staff to support that appropriate reimbursement, clinical severity of illness, and risk of mortality is captured for the level of service rendered to all patients. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and practice outcomes. Educates all members of the patient care team on an ongoing basis.

1. Core documentation review

• Assess documentation for completeness, specificity, and compliance with coding guidelines
• Identify missing elements that impact code selection and medical necessity
• Apply best practices for querying providers to ensure accurate documentation

2. Inpatient coding and compliance

• Link provider documentation to ICD and CPT® code assignment
• Review documentation requirements, including medical necessity, provide guidance on documentation improvement opportunities
• Ensuring compliance with payer policies, NCCI edits, and federal regulations

3. Risk adjustment and quality reporting

• Understand documentation requirements for HCC and risk adjustment coding
• Support accurate reporting for quality initiatives and value-based care
• Identify documentation gaps that affect population health and reimbursement

4. Communication and provider education

• Provide feedback to providers on documentation deficiencies and improvement needs
• Educate clinicians on best practices for supporting coding and audit readiness
• Enhance collaboration between coding, billing, and clinical staff to reduce denials and compliance risk

Qualifications:

Education:

• Must have an Associate’s degree in Healthcare, Nursing or related field, or equivalent combination of education & experience.
• Must have training in medical terminology, anatomy, and physiology.
• Must have training and certification in coding, or equivalent combination of education and experience.
• Three to five years CDI experience preferred.

Licensure:

• Must possess a certification; Certified Documentation Expert Inpatient (CDEI), Certified Clinical Documentation Specialist (CCDS), or Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) with coding or clinical documentation integrity experience.
• Must agree to obtain CDEI or CCDS within first year of employment.

Experience:

• In-depth knowledge of medial record content.
• In-depth knowledge of coding/classification systems (ICD & CPT) and associated coding guidelines.
• Experience with compliant healthcare documentation, HCC coding requirements, alternate payment models in a multi-facility, revenue cycle experience.
• Basic computer skills.

Skills:

• Should be knowledgeable in use of coding software (encoders).
• Should be knowledgeable in LDC/NCD (or how to look this up) and Quality Measures.
• Should be knowledgeable in coding guidelines.
• Requires excellent observation skills, analytical thinking, problem solving, plus excellent verbal/ written and presentation skills.
• Must have the ability to balance and juggle multiple tasks, projects, and requests; meet deadlines.
• Ability to communicate effectively via remote Teams application.

Physical Effort:

• Manual and finger dexterity.
• Sitting for extended periods of time.
• Ambulate to provider practices or group meetings, as needed.
• Requires corrected vision and hearing to normal range.
• Requires working under stressful conditions.

Interpersonal Skills:

• Excellent interpersonal skills in dealing with co-workers, providers, physicians and their office staff, Practice Mangers, and other Work Areas.
• Must have strong initiative, excellent judgment, good problem-solving skills, and excellent interpersonal skills.
• Develop and maintain positive working relationships among all levels of the organization to effectively develop and implement key initiatives.