Clinical Documentation Specialist

Job description

Job Summary The Clinical Documentation Specialist (CDS) performs clinical documentation improvement (CDI) activities to support the accuracy, quality, and completeness of patient records at facilities. This role ensures that coded diagnoses and procedures reflect the patient's clinical status and care provided. The CDS collaborates with providers through education and the physician query process, ensuring medical records accurately reflect patient severity of illness and support continuity of care, appropriate quality metrics, and regulatory compliance. Essential Functions: - Analyzes inpatient clinical records to identify opportunities for improving documentation accuracy, ensuring assigned codes reflect patient severity and acuity. - Adheres to corporate recommended CDI workflows and uses CDI and medical records software, such as 3M 360 Encompass and Iodine Interact, to support documentation practices. - Utilizes approved physician query processes to clarify documentation, ensuring queries are compliant, necessary, and non-leading, and follows up daily on unanswered queries. - Conducts follow-up reviews of patient records to identify new documentation opportunities and ensures ac...