Clinical Documentation Specialist

Job description

Current Employees: If you are currently employed at SOMC please log into UKG Pro to use the internal application process. Department: Health Information Management: Shift/schedule: Full Time (40 hrs/wk): GENERAL SUMMARY: Clinical Documentation Specialist works under the supervision of the Health Information Manager. The primary job function of the Clinical Documentation Specialist is to conduct concurrent reviews of medical records to ensure that documentation requirements are met to establish severity of illness, risk of mortality, clinical validation along with optimal reimbursement and compliance. Reviews medical records from a clinical prospective to ensure that each diagnoses is clinically validated and the appropriate DRG is assigned to the case. CDI interacts with providers to ensure the documentation reflects the necessary verbage for compliant coding. Documentation specialists are also responsible to work on e on one with providers to obtain answers to queries and do the necessary education to decrease the need for queries. The reviews also assist in identifying hospital acquired conditions to flag these records for additional review of potential charge credit opportunitie...