Clinical Documentation Integrity Specialist

About the role

The Clinical Documentation Improvement Specialist reviews inpatient charts to ensure accurate DRG assignment and comprehensive documentation that supports clinical care, severity of illness, and mortality risk, impacting the Case Mix Index.

They collaborate with physicians, nurses, ancillary staff, and coders to identify diagnoses and procedures, assign DRGs, and conduct second-level reviews as needed. The role also involves educating peers and providers on CDI topics, reviewing denials, and assisting with appeals.

Responsibilities

• Perform chart reviews to ensure accurate DRG assignment and comprehensive clinical documentation.
• Collaborate with physicians, nurses, ancillary staff, and coders to identify diagnoses and procedures.
• Conduct second-level reviews as needed.
• Educate peers and providers on CDI topics.
• Review denials and assist with appeals.
• Clarify documentation with healthcare providers.
• Enter data accurately into EPIC and CDI software.
• Participate in software testing and upgrades.

Requirements

• 2 years of clinical documentation and nursing experience.
• RHIA certification.
• Associate's degree in nursing or a related field.

Skills

• Effective communication.
• Knowledge of CDI processes and documentation accuracy.
• Proficiency in EPIC and CDI software.