The Clinical Documentation Specialist is responsible for improving the overall integrity of medical records documentation. The CDI Specialist uses clinical and coding knowledge to conduct clinically based concurrent and retrospective chart reviews to evaluate the clinical documentation of clinical services by identifying opportunities for improving timely, accurate and completeness of medical record documentation. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. The Clinical Documentation Improvement Specialist plays a significant role in optimizing appropriate reimbursement for acute care services.
The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job. Incumbents may be requested to perform tasks other than those specifically presented in this description.