Clinical Documentation Specialist Senior (FT, REMOTE)
Summary
Senior Clinical Documentation Integrity Specialist reviews medical records, collaborates with providers and coding teams to ensure accurate documentation, coding, and DRG assignment for patient severity and mortality risk.
The Clinical Documentation Integrity Specialist II(CDI) is responsible for utilizing independent clinical judgement in facilitating the integrity, overall quality, accuracy, and completeness of provider-based clinical documentation in the medical record. This position is responsible for collaborating with healthcare providers to ensure the documentation in the medical record accurately reflects the severity of illness and risk of mortality of the patient. The CDI Specialist assesses the clinical documentation through extensive reviews of the medical record, interaction with all members of the healthcare team and the Healthcare Information Management (HIM) Coding team to ensure appropriate coding and Diagnosis Related Group (DRG) assignment for the level of services rendered to the patient and to ensure that the clinical information utilized in profiling and reporting outcomes is complete and accurate.