About this role
Role Overview
- Responsible for improving the accuracy, completeness, and integrity of clinical documentation
- Performs comprehensive reviews of inpatient medical records
- Identifies opportunities to improve capture of SOI, ROM, HCC, CC/MCC, DRG accuracy, and risk adjustment elements
- Collaborates with physicians and advanced practice providers to clarify ambiguous, incomplete, or conflicting documentation
- Applies Intermountain clinical program criteria, service line guidance, and national evidence-based clinical indicators to validate diagnoses
- Evaluates documentation for impacts on mortality metrics, PSI/HAC, infection prevention, VBP, CMS Star Ratings, and other publicly reported outcomes
Requirements
- Degree in a clinical field (e.g. RN, RRT, LCSW)
- Three years of clinical experience in an adult acute care setting OR one year of experience as a Clinical Documentation Improvement Specialist in an adult acute care setting
- Proficiency in Quality and Infection Prevention reporting
- Proficiency in Risk adjustment and Proactive Care Models
- Experience with Microsoft Office products
- Clinical experience in ICU, CCU, primary care, or intermediate care
- Knowledge of EMR systems
- CCS, CIC, CCDS or CDIP
Benefits
- Generous benefits package covering a wide range of programs
- Flexible work options where approved