Clinical Documentation Specialist

The Clinical Documentation Specialist works under the Clinical Documentation Integrity Program Manager to improve the quality and completeness of clinical documentation, ensuring it accurately reflects patient severity of illness and risk of mortality. This hybrid role involves collaborating with physicians, case management, nursing, and coding staff to clarify diagnoses, enhance coding specificity, and maintain compliance with coding guidelines. The position requires conducting concurrent documentation reviews, performing DRG reconciliation, and serving as a resource for medical terminology and ICD-10-CM coding guidelines.