Documentation Specialist Jobs

About The Position

Requirements

• High school diploma or GED at minimum.
• At least 2 years performing CDI reviews in an acute-care facility or bedside experience.
• At least one of the listed credentials or licenses upon hire: Certified Clinical Documentation Specialist (CCDS), RN state license, Registered Health Information Administrator (RHIA), or Clinical Documentation Integrity Practitioner (CDIP).

Nice To Haves

• Associate degree or college diploma in a clinical field, such as nursing or health information, or foreign-trained medical graduate.
• Three years of utilization review, coding, or case management experience.

Responsibilities

• Review and analyze clinical information in the electronic health record to identify potential gaps in physician or provider documentation.
• Formulate credible clinical documentation clarifications to improve documentation of principal diagnoses, comorbidities, present-on-admission status, quality core measures, and patient safety indicators.
• Confirm or assign a working diagnostic related group (DRG) and severity level using coding rules and guidelines, with follow-up reviews as required by length-of-stay standards.
• Extract essential data for reporting and tracking, including Joint Commission record reviews, core measures, severity of illness and risk of mortality assessments, patient safety indicators, and revenue optimization criteria; dedicate full attention to core measure responsibilities.
• Engage in ongoing queries with physicians and providers to clarify and enhance documentation specificity in medical records.
• Conduct post-discharge reviews comparing clinical documentation integrity and coding-assigned codes.
• Communicate with physicians, nurse practitioners, case managers, coders, and other care-team members to support comprehensive medical-record documentation reflecting treatment and decision-making.
• Identify trends related to documentation issues, provider-specific concerns, and code-specific needs.
• Present to peer audiences on topics such as clinical diagnoses, regulatory changes, guidelines, and new practices.
• Mentor and precept Clinical Documentation Specialist Level 1 staff.
• Initiate clinical documentation integrity projects for process improvement.
• Create trend reports, manage queries directly with physicians, and provide feedback to leadership.