ClinicalDocumentationImprovementSpecialist

## Accountabilities Conduct concurrent and retrospective reviews of inpatient medical records to identify opportunities for documentation improvement and coding accuracy. Initiate physician queries and collaborate with providers to clarify ambiguous, incomplete, or conflicting documentation to support accurate coding and clinical representation. Facilitate documentation that appropriately reflects severity of illness, risk of mortality, complexity of care, case mix index (CMI), length of stay (LOS), and resource utilization. Educate physicians, clinical staff, and stakeholders on documentation standards, coding guidelines, reimbursement requirements, and regulatory expectations. Apply coding principles, reimbursement guidelines, and documentation standards to support accurate working DRG assignments and clinical documentation integrity. Collaborate with coding teams, auditors, quality improvement professionals, and other stakeholders to resolve documentation issues and improve data quality. Conduct focused reviews related to mortality, patient safety indicators (PSIs), and other quality or compliance initiatives identified by leadership. Monitor evolving documentation, coding, and regulatory requirements to ensure ongoing compliance and best practices. Assist with onboarding, training, and mentoring new CDI team members. Contribute to continuous improvement initiatives aimed at enhancing documentation quality, reporting accuracy, and operational effectiveness. Requirements Associate Degree in Nursing required; Bachelor of Science in Nursing (BSN) preferred. Active and unrestricted U.S. Registered Nurse (RN) license required. Three to five years of recent clinical experience in medical-surgical, intensive care, telemetry, emergency department, or related acute care settings. Strong knowledge of clinical documentation improvement practices, coding methodologies, reimbursement structures, and healthcare quality measures. Experience working with electronic medical recor