Assesses clinical documentation through extensive review of the medical record
Interacts with providers, nursing staff, and coding staff to ensure appropriate reimbursement
Conducts post discharge reconciliation for comparative analysis of CDI specialist and final coding
Formulates appropriate clinical documentation clarifications
Works with providers and Advanced Practitioners to improve documentation
Participates in departmental education, training, and orientation sessions
Assists in overall quality and completeness of the health record

Associates Degree, Nursing (Required)
Bachelors Degree, Nursing or healthcare related (Preferred)
5-6 years Nursing experience, preferred pt care, critical care, utilization management, quality, or patient navigator (Required)
3-4 years CDI experience (Required)
Knowledge of ICD-10 and coding rules and regulations
Experience with 3M 360 or other encoder

Clinical Documentation Specialist III – Registered Nurse

Key skills