Clinical Documentation Improvement Specialist
About the role
The RN Clinical Documentation Improvement (CDI) Specialist acts as a liaison between clinical and coding teams, focusing on enhancing documentation accuracy to support revenue management and patient care. They review inpatient records promptly, evaluate diagnoses and procedures, and collaborate with medical staff to clarify and improve documentation. The role involves providing education on documentation standards, analyzing clinical information to determine appropriate DRGs, and supporting the overall System Case Mix Index. The specialist participates in ongoing record reviews, formulates queries for unclear or missing documentation, and promotes interdisciplinary collaboration to ensure comprehensive, accurate records. They also analyze statistical data for improvement opportunities and work closely with coding professionals to ensure precise coding and documentation.
Qualifications
- Minimum of three years RN work experience
- BSN strongly preferred
- Clinical knowledge of Anatomy and Physiology
Skills
- Excellent communication and collaboration skills
- Ability to review and analyze clinical documentation effectively
- Proficiency in identifying documentation gaps and formulating queries
Responsibilities
- Review inpatient records within 24-48 hours of admission and throughout hospitalization
- Ensure accurate DRG assignment, severity of illness, and risk of mortality
- Educate healthcare providers on documentation best practices
- Collaborate with interdisciplinary teams to resolve documentation issues
- Support coding accuracy and documentation completeness
- Participate in data analysis to identify improvement strategies