Clinical Documentation Specialist

Responsibilities: Coordinates and maintains the Clinical Documentation Improvement Program to ensure accurate representation of patient care and compliance. Acts as a liaison between clinical, coding, and quality teams to improve documentation and reporting of hospital outcomes.

Requirements: Requires a Bachelor's degree in a healthcare field or equivalent experience, with 3-5 years in clinical practice, inpatient coding, or CDI. Must hold certifications such as CCDS, CDIP, or CCS and be proficient in ICD-10 coding and DRG assignment.

Key skills: ICD-10-CM/PCS Coding, DRG Assignment, Clinical Documentation Improvement, Query Processes, CMS IPPS, Risk Adjustment Methodologies, Value-Based Purchasing, Microsoft Excel, MedHost, Iodine CDI Software, Clinical Quality, Utilization Management, Case Management, HIPAA Compliance, Data Analysis, Interpersonal Communication

Keywords: Clinical Documentation Improvement, CDI, ICD-10-CM/PCS, DRG, CCDS, CDIP, CCS, CMS, IPPS, MedHost, Iodine CDI, HIPAA, Utilization Management, Case Management, Health Information Management, MCC/CC, Medicare Part A, Medicare Part B, Clinical Quality, Revenue Cycle Operations, Risk Adjustment, Value-Based Purchasing, Microsoft Word, Microsoft Excel, Microsoft PowerPoint, Microsoft Outlook, Microsoft Access