Clinical Documentation Improvement Specialist - RN | Clinical Documentation Integrity | Day | Full-Time

Responsible for facilitating improvement in inpatient clinical documentation through concurrent review of the medical record for accurate physician documentation of diagnoses based on clinical evidence present in the chart, application of official ICD-10-CM coding guidelines, and interaction with physicians and other clinicians. Identifies opportunities for improvement in clinical documentation and queries the physician for clarification to support more specific diagnoses. Collaborates with physicians and coders to obtain documentation that most accurately reflects patient's severity of illness and risk of mortality. Educates all members of the patient care team on an ongoing basis.