Clinical Documentation Specialist

Job Responsibilities

• Examine medical records to ensure documentation is accurate, complete, and reflective of the patient's clinical status.

• Detect inconsistencies, ambiguities, or missing information in the medical record that may impact coding, compliance, or patient care and request provider clarifications as necessary.

• Verify that clinical documentation supports correct ICD-10-CM/PCS and CPT coding for proper reimbursement and collaborates with the coding/revenue cycle team.

• Ensure that documentation and provider queries align with regulatory standards, including CMS guidelines and organizational policies.

• Communicates and establishes relationships with physicians and clinical staff to share insights, trends and education to improve documentation practices.

• Contributes to organizational quality improvement initiates by ensuring robust and accurate documentation related to MHACs, PPCs, PSIs, SOI/ROM and mortality.

• Track and report on metrics related to documentation quality, such as query response rates or documentation accuracy.

• Provide guidance and education on documentation best practices and standards to physician and clinical staff to support ongoing improvement.

• Assist in internal and external audits by ensuring proper documentation and addressing identified issues.

• Maintains and enhances current medical, coding and CDI knowledge via participating in continuing education offerings.

Qualifications include:

• BSN or Equivalent

RN (Registered Nurse)

• Minimum of 5 years inpatient clinical experience with 2-5 years clinical documentation improvement experience

• Experience with Solventum/3M 360 preferred

• Current Maryland license

• Relevant certification required, e.g. CDIP or CCDS

• Maintains current working knowledge of Coding Clinic Guidelines and federal updates to DRG system (MS, APR, AP etc)

• Knowledge of medical terminology, anatomy, physiology, microbiology, and disease processes.