Facilitate improvements in clinical documentation quality, completeness, and accuracy to support patient care and reimbursement outcomes.
Analyze clinical records and identify documentation opportunities related to severity of illness, risk of mortality, and coding accuracy.
Assign working DRGs for inpatient admissions and support appropriate code assignment.
Collaborate with physicians, Nurse Case Managers, and multidisciplinary care teams to obtain complete and accurate clinical documentation.
Query providers to clarify incomplete, conflicting, or ambiguous documentation using approved processes.
Perform clinical record abstracting and data collection to support reimbursement, quality initiatives, and outcome reporting.
Educate physicians and care teams on documentation standards, coding updates, MS-DRG changes, and coding guidelines.
Ensure the accuracy and integrity of medical record data prior to billing and claims submission.
Partner with Patient Accounting and coding teams to resolve reimbursement and documentation-related issues.
Support quality management and continuous improvement initiatives through data analysis, education, and documentation integrity efforts.

Associate’s or Bachelor’s degree in Health Information Management and/or a Certified Coding Specialist (CCS) credential.
Minimum of two years of inpatient clinical coding experience or successful completion of a coding competency assessment.
CCS, CDIP, or CCDS certification required.
Familiarity with concurrent coding models strongly preferred.
Proficiency with Encoder/Grouper technology and strong computer skills.
Understanding of clinical documentation improvement (CDI) principles and coding compliance requirements.
Ability to effectively communicate and collaborate with physicians and interdisciplinary teams.
Strong analytical, critical thinking, and problem-solving skills.
Commitment to maintaining data integrity, coding accuracy, and regulatory compliance.
Nursing degree and/or registered nurse experience preferred.

Clinical Documentation Specialist

Key skills