Clinical Documentation Coordinator
Listed on 2026-10-16
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Healthcare
Healthcare Compliance, Medical Records, Healthcare Administration, Health Informatics
Responsibilities
The role involves managing the Clinical Documentation Integrity (CDI) program under supervision, focusing on daily workflow, GME and medical staff education, and inpatient record reviews. The position aims to ensure accurate documentation of care, patient severity, and risk of mortality to support proper reimbursement and quality reporting. It includes conducting concurrent and retrospective reviews to evaluate utilization, documentation accuracy, and compliance with external payer and regulatory requirements.
ResponsibilitiesThe role involves managing the Clinical Documentation Integrity (CDI) program under supervision, focusing on daily workflow, GME and medical staff education, and inpatient record reviews. The position aims to ensure accurate documentation of care, patient severity, and risk of mortality to support proper reimbursement and quality reporting. It includes conducting concurrent and retrospective reviews to evaluate utilization, documentation accuracy, and compliance with external payer and regulatory requirements.
Qualifications- Associate's degree in nursing (bachelor’s preferred) or medical degree from a recognized institution.
- Minimum of 2 years of clinical experience in acute care settings for nurses, with 1-3 years of clinical documentation integrity experience preferred.
- Knowledge of Prospective Payment System, Diagnosis Related Group optimization, and inpatient admission criteria.
- Technical proficiency in electronic health records, office software, and CDI/Coding applications.
- Current RN license if applicable; certifications like CDIP, CCDS, CCS, or ICD-10 are preferred.
- Strong clinical knowledge, understanding of disease processes, and excellent communication and critical thinking skills. Ability to work independently in a fast-paced environment.
- Oversee daily CDI operations and staff education.
- Perform clinical review of inpatient records to support accurate documentation and reimbursement.
- Ensure compliance with payer and regulatory standards.
- Maintain knowledge of coding, reimbursement systems, and clinical policies.
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