Clinical Documentation Improvement Specialist

​Lake Regional Health System


The Clinical Documentation Improvement Specialist is responsible for concurrently reviewing medical records to identify vague, inconsistent or incomplete documentation within the medical record and assigns the most appropriate medical severity diagnostic related group (MS-DRG).

Job Description:

Reviews concurrently selected populations of medical records to identify the principal and/or secondary diagnoses. Appropriately assigns the MS-DRG that most accurately reflects the severity of illness and risk of mortality of the patient based upon the clinical evidence documented at the time of the record review.
Demonstrates knowledge and understanding of severity-based DRG systems; All Patient Refined and Medicare Severity (AP-DRG) and Medical Severity Diagnostic Related Group System (MS-DRG).
Demonstrates the ability to utilize the licensed software tool to perform and record daily medical record reviews.
Queries and Interacts with the physician and/or other designated members of the healthcare team as needed to ensure that vague or incomplete documentation is clarified within the medical record in a timely manner.
Works with other departments such as coding, corporate compliance, quality, and finance to support Corporate Goals.
Participates in the ongoing education of physicians, nurse practitioners, physician assistants, and other healthcare team members in an effort to identify medical record documentation improvement opportunities employing conflict resolution skills as necessary.
Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record.
Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies.

Required Qualifications:

Obtain and maintain CCDS or Coding Certification within 2 years of employment
Extensive knowledge of disease processes and clinical outcomes
Must speak English fluently and write English in understandable terms.

Preferred Qualifications:

1-2 years of coding experience preferred.
Strong financial and analytical skills preferred.
Word, Outlook, Excel experience preferred.

Education Qualifications:

Bachelor’s Degree Preferred

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