Clinical Documentation Improvement Specialist

- Concurrently review inpatient medical records for clear consistent, concise, legible and accurate documentation to reflect the patient’s severity of illness and intensity of services. - Generate and utilize queries to clarify physician documentation whenever there is conflicting, ambiguous or incomplete information in the medical record regarding any significant reportable condition or procedure. - Complete analysis of clinical information to identify gaps in clinical documentation. To “bridge the gap” utilize the physician advisor for clarification of clinical presentation. - Collaboratively work with HIM Leadership, Coders, Coding Quality Educators/Reviewers and peers to improve accuracy of final DRG. - Collaborate and provide...