Clinical Documentation Improvement Specialist

Responsibilities

• Perform concurrent review of inpatient medical records to identify opportunities for improving documentation quality
• Identify cases where diagnoses and procedures are absent, incorrectly stated, or improperly recorded
• Confer with caregivers regarding required additional documentation
• Ensure medical records reflect patient diagnoses, treatments, and severity of illness by time of discharge
• Facilitate and enhance the coding and DRG assignment process
• Follow TJC, Medicare, third party payer, and ICD-10-CM guidelines
• Assist attending physicians and healthcare providers in the patient care documentation process

Requirements

• Bachelor's Degree in Nursing
• Registered Nurse license
• 2 years of relevant experience

Preferred Qualifications

• 2-4 years of relevant experience

Benefits

• Medical, dental, and vision coverage with significant employer contribution
• Paid time off including sick and vacation time
• 11 paid holidays
• State retirement plan or alternative retirement plan with generous employer contributions