Clinical Documentation Specialist

Facilitates and obtains appropriate clinical documentation for clinical conditions and procedures to support severity of illness, expected risk of mortality, and complexity of care.

Responsible for concurrent inpatient medical record reviews for Medicare, Medicaid, and commercial payers. Generates queries and follows up with physicians to clarify ambiguous or conflicting documentation.

Key responsibilities include:

• Clarify clinical documentation to ensure accuracy and integrity in the medical record.
• Support diagnosis coding and appropriate level of service documentation.
• Work with physicians on assigned patient care units through concurrent review during the inpatient stay.
• Request clarification from physicians as needed prior to discharge.
• Ensure severity of illness and level of service are accurately documented.
• Follow up on CDI queries to ensure appropriate documentation is recorded.
• Discuss clinical documentation requirements and coding questions with physicians.
• Demonstrate knowledge of ICD-10-CM, ICD-10-PCS, MS-DRG, APR NY, and APR National grouper logic.
• Conduct follow-up reviews to confirm clarifications are reflected in the chart.
• Reconcile reviewed cases and confer with providers to finalize diagnoses.
• Educate medical staff on documentation opportunities impacting medical record accuracy.
• Input outcome data into CDI software and maintain files for tracking and trending audit results.
• Communicate findings related to potential or missed diagnoses and revenue impact from chart audits.
• Exercise independent judgment within defined procedures.
• Perform related duties as required.