Clinical Documentation Improvement Specialist
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Job Description
Clinical documentation specialist reviewing inpatient records for accurate diagnoses, severity, and DRG reimbursement. Supporting physicians, coders, and appeals at Cooper Norcross Health.
Responsibilities:
- Review inpatient medical records concurrently to ensure clear, consistent, concise, legible, and accurate documentation reflecting patients’ severity of illness and intensity of services
- Generate and utilize queries to clarify physician documentation when medical records contain conflicting, ambiguous, or incomplete information about significant reportable conditions or procedures
- Analyze clinical information to identify gaps in clinical documentation
- Utilize the physician advisor to clarify clinical presentation
- Collaborate with HIM Leadership, coders, Coding Quality Educators/Reviewers, and peers to improve final DRG accuracy
- Provide educational support to physicians, nurses, and ancillary staff to improve clinical documentation processes
- Facilitate documentation modifications through interaction with physicians, nursing staff, caregivers, and Health Information coding staff to capture appropriate reimbursement and clinical severity
- Review cases denied for medical necessity by auditing agencies and assist the physician advisor with appeals by collecting pertinent information
Requirements:
- 3-5 years of experience required
- High School/GED Required
- Bachelor's Degree Required
- Certified Clinical Documentation Specialist Certification preferred
- Certified Documentation Improvement Practitioner preferred
- Registered Nurse, any state, preferred
- Professional team player, able to communicate well with others on all levels required
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