Clinical Documentation Specialist-III Inpatient
Listed on 2026-10-02
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Healthcare
Medical Records, Healthcare Administration
Welcome! We’re excited you’re considering an opportunity with us! Below, you’ll find other important information about this position.
Responsible for strategic management of service line integration throughout the system. Capable of focused and second level reviews. Performs independently at the highest level of expectation. Assists Manager on specific projects as assigned.
MINIMUM QUALIFICATIONS
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EDUCATION, CERTIFICATION, AND/OR LICENSURE:
Certified Documentation Integrity Practitioner (CDIP) through the American Health Information Management Association(AHIMA)
Certified Clinical Documentation Specialist (CCDS) through the Association of Clinical Documentation Integrity Specialists (ACDIS)
Certified Documentation Expert Inpatient (CDEI) through the American Association of Professional Coders (AAPC)
EXPERIENCE:
Three (3) years clinical RN experience in Inpatient acute care setting OR
Three (3) of clinical LPN experience in Inpatient acute care setting.
CORE
DUTIES AND RESPONSIBILITIES:
The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
Assists CDI Manager in the planning, execution, and delivery of ahigh-qualityCDI department.
Assists CDI Manager in the design, collection, and reporting of relevant data to support the System CDI Program.
Collaborates with CDI Educator/Manager for provider educational opportunities.
As a CDI system service line expert, responsible for integration and strategic management of service line, keeping the service line team focused on CDI greatest impact.
Attends all revenue integrity meetings related to their designated system service line.
Capable of efficient review and timely results for focused DRGs and second level reviews.
In collaboration with the providers and staff, identifies and recordsprinciplediagnoses, secondary diagnoses, procedures, and assigns a working Diagnostic Related Group (DRG).
Conducts initial concurrent review and ongoing re-reviews for all selected admissions by documenting findings regarding DRGs, APR-DRGs and Value Based Purchasing/Quality measures.
Identifies need to clarify documentation through quality audits in records and initiates communication with physician, nurse, or patient care coordinator by utilizing the appropriate query tools in order to capture the documentation in the medical record that accurately supports the patient’s severity of illness.
Provides information and ongoing education as necessary to providers and staff on documentation issues, guidelines, and unanswered queries
Promotes compliance with CMS, Medicare documentation, and coding and billing regulations.
Participates in the processes to assess and improve the services provided and compliance with regulatory requirements. Report results assessment and improvement processes to the appropriate administrative levels.
Collaborate with the Quality Department to ensure documentation meets quality initiative standards used for measuring and reporting hospital and provider outcomes.
Collects,analyze sand submits timely, accurate and complete reports of clinical documentation information used for measuring and reporting Hospital and Provider outcomes data.
Works with the Coding Specialists on any issues that arise concerning documentation, providers, and queries to enhance the concurrent process to enable prompt coding.
Serves as a mentor and advises Level I and II CDI Specialists.
PHYSICAL REQUIREMENTS: The…
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