Clinical Documentation Specialist Jobs in the United States
Houston Methodist
null, WA
FLSA STATUS** Exempt **QUALIFICATIONS** **EDUCATION** + Medical School graduate where Western Medicine is practiced **EXPERIENCE** + One year of clinical experience preferred **LICENSES AND CERTIFICATIONS** **Required** **Preferred** + CCDS - Clinical Documentation Specialists (ACDIS) **or** + CDIP - Certified Documentation Integrity Practitioner (AHIMA) **or** + CCS - Certified Coding Specialist (AHIMA) **SKILLS AND ABILITIES** + Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations + Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security + Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles + Demonstrates knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures + Demonstrates accountability and professional development + Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication + Regular significant contacts with other personnel throughout the institution (including but not limited to - physicians and their staff, mid-level providers, mid-level staff, coders, Case Managers). Disaster, Severe Weather Events, etc) regardless of selection below._ + On Call* No **TRAVEL**** _**Travel specifications may vary by department**_ + May require travel within the Houston Metropolitan area No + May require travel outside Houston Metropolitan area No **QUALIFICATIONS** **EDUCATION** + Medical School graduate where Western Medicine is practiced **EXPERIENCE** + One year of clinical experience preferred **LICENSES AND CERTIFICATIONS** **Required** **Preferred** + CCDS - Clinical Documentation Specialists (ACDIS) **or** + CDIP - Certified Documentation Integrity Practitioner (AHIMA) **or** + CCS - Certified Coding Specialist (AHIMA) **Company Profile:** Houston Methodist is one of the nation's leading health systems and academic medical centers.
Houston Methodist
null, WA
FLSA STATUS** Exempt **QUALIFICATIONS** **EDUCATION** + Medical School graduate where Western Medicine is practiced **EXPERIENCE** + One year of clinical experience preferred **LICENSES AND CERTIFICATIONS** **Required** **Preferred** + CCDS - Clinical Documentation Specialists (ACDIS) **or** + CDIP - Certified Documentation Integrity Practitioner (AHIMA) **or** + CCS - Certified Coding Specialist (AHIMA) **SKILLS AND ABILITIES** + Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations + Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security + Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles + Demonstrates knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures + Demonstrates accountability and professional development + Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication + Regular significant contacts with other personnel throughout the institution (including but not limited to - physicians and their staff, mid-level providers, mid-level staff, coders, Case Managers). Disaster, Severe Weather Events, etc) regardless of selection below._ + On Call* No **TRAVEL**** _**Travel specifications may vary by department**_ + May require travel within the Houston Metropolitan area No + May require travel outside Houston Metropolitan area No **QUALIFICATIONS** **EDUCATION** + Medical School graduate where Western Medicine is practiced **EXPERIENCE** + One year of clinical experience preferred **LICENSES AND CERTIFICATIONS** **Required** **Preferred** + CCDS - Clinical Documentation Specialists (ACDIS) **or** + CDIP - Certified Documentation Integrity Practitioner (AHIMA) **or** + CCS - Certified Coding Specialist (AHIMA) **Company Profile:** Houston Methodist is one of the nation's leading health systems and academic medical centers.
Hackensack Meridian Health
Hackensack, New Jersey
Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, Health Information Management Department coding staff, and Emergency Trauma Department (ETD), to ensure clinical documentation reflects the level of service rendered to patients is complete and accurate. Responsibilities: A day in the life of a Clinical Documentation Specialist RN at Hackensack Meridian Health includes: Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record.
Saint Luke's Health System
Kansas City, MO
Our priority is patient care in that we interact with patients daily and have the opportunity to bring something positive to their day to ensure Saint Luke’s is“The Best PlaceToGet Care, The Best PlaceToGive Care.” . Saint Luke’s has a strong nurse governance and we encourage all of our nurses to participate and help us make Saint Luke’sThe Best PlaceToGet Care, The Best PlaceToGive Care.
CareWell Health
East Orange, NJ
Facilitates updates to the clinical documentation through interactions with physicians, nursing, HIM and coding staff and other peer to peer interactions, to ensure appropriate reimbursement for the level of service rendered to all patients with a DRG based payer. Improves the overall quality and completeness of clinical documentation by performing detailed concurrent, retrospective and post-bill reviews of the clinical documentation for quality improvement and financial impact on Inpatients.
Huntsville Hospital Health System
Huntsville, Alabama
With 971 beds, a specialized Orthopedic & Spine Tower, a Level III Regional Neonatal ICU, and the largest Emergency Department and Level 1 Trauma Center in the state with our own specialized Red Shirt Trauma Program, there are many opportunities to apply your knowledge and skills. We offer a training center on campus for continuing education, Shared Governance Program, Clinical Ladder for professional development, The Daisy Award, and if you are a new grad, a Nurse Residency Program to help you transition from student to professional nurse.
Ascension
$82825 - $115453
Remote, undefined
Our legitimate email communications will always come from an @ascension.org email address; do not trust other domains, and an official offer will only be extended to candidates who have completed a job application through our authorized applicant tracking system. Recognized as one of the Best 150+ Places to Work in Healthcare and a Military-Friendly Gold Employer, you’ll find an inclusive and supportive environment where your contributions truly matter.
SDVInternational
Camp Lejeune, NC
If the CDIS determines a provider’s documentation is not improving, the CDIS shall recommend to the Task Order Government POC a corrective action plan to identify specific areas of improvement, a remediation plan that includes a timeline in which to achieve positive results and a follow-up plan. communicate with physicians, case managers, coders and other health care team members to obtain comprehensive medical record documentation to support the severity of illness, expected risk of mortality, and complexity of care provided to the patient.
Temple Health
Philadelphia, PA
Temple Health consists of Temple University Hospital (TUH), Fox Chase Cancer Center, TUH-Jeanes Campus, TUH-Episcopal Campus, TUH-Northeastern Campus, Temple Physicians, Inc., and Temple Transport Team. The Sr Coding and CDI Specialist has the overall responsibility for conducting in-depth reviews of clinical documentation to ensure compliance with coding guidelines, regulatory requirements, clinical validation, and overall accuracy of coding for the Temple University Health System.
Catholic Health System
Buffalo, NY
Summary: Under the direction of the Manager Clinical Documentation Integrity, the Lead Clinical Documentation Integrity Specialist is responsible for leading various training and operational matters including appropriate scheduling and coverage of cases, reconciling queries and DRG discrepancies, educating physicians, monitoring the program, and refining the process as needed, as well as training and mentoring new and current staff with regard to compliant documentation. Knowledge of ICD-10, current knowledge of coding clinics including recent changes/updates, and understanding of the various DRG methodologies (AP-DRG and MS-DRG) .
Duly Health and Care
Downers Grove, Illinois
The Clinical Documentation Specialists will build strong collaborative relationships with providers and office staff, conduct both in-person trainings, and remain current on evolving Medicare, AMA, ICD-10, and risk adjustment guidelines. The compensation for this role includes a base pay range of $85,616-$100k with the actual pay determined by factors such as skills, experience, education, certifications, geographic location, and internal equity.
Ascension Health
Franklin, WI
Collaborate with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient's discharge. Ascension is a leading non-profit, faith-based national health system made up of over 134,000 associates and 2,600 sites of care, including more than 140 hospitals and 40 senior living communities in 19 states.
Alura Workforce Solutions
Fountain Valley, CA
DESCRIPTION The Clinical Documentation Specialist (CDS) is responsible for performing concurrent reviews of inpatient medical records to ensure clinical documentation accurately reflects the patient's severity of illness, risk of mortality, intensity of services, and quality of care provided. The CDS collaborates closely with physicians, coders, CDI leadership, and ancillary departments to identify documentation clarification opportunities and ensure medical records support appropriate reimbursement and quality outcomes.
Alura Workforce Solutions
Fountain Valley, CA
DESCRIPTION The Clinical Documentation Specialist (CDS) is responsible for performing concurrent reviews of inpatient medical records to ensure clinical documentation accurately reflects the patient's severity of illness, risk of mortality, intensity of services, and quality of care provided. The CDS collaborates closely with physicians, coders, CDI leadership, and ancillary departments to identify documentation clarification opportunities and ensure medical records support appropriate reimbursement and quality outcomes.
Midland Health
Midland, Texas
Registered Nurse – current license (ADN or BSN) with 5 years acute care experience or comparable degree in a healthcare-related discipline with 3-5 years recent coding experience and certification of one of the following preferred: Certified Coding Specialist (CCS), Certified Documentation Integrity Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS). • Concurrently queries the medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality.
Catholic Health
$70000 - $95000
Melville, New York
Job Details: The Professional Fee (ProFee) Clinical Documentation Specialist (CDS) will serve as an advisor and expert resource for providers to improve the accuracy of clinical documentation to support patient complexity and acuity, risk profiles and professional fee billing. Pre-visit provider support – Provide support to providers through patient record reviews in advance of patient visits, focused on the following: Recapture of HCCs and other potential chronic diagnoses .
Yuma Regional Medical Center
Yuma, AZ
Recommends and implements, under collaboration and direction of Director and physician leadership, specific tools to support medical record clinical documentation including but not limited to forensic inpatient record assessment, analysis, and review; population of databases for statistical evaluation of same; coordinates future education projects; develops and implements plans for both formal and informal education of medical staff, nursing, and other clinical staff; identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation; facilitates multidisciplinary team in efforts for clinical documentation improvement. Utilizes knowledge of Core Measure and Patient Safety Indicators when reviewing and analyzing selected inpatient medical records for all of the following, including but not limited to: chief complaint; presentation; history of present illness; past medical, surgical, and social history; clinical status of patient; diagnostic tests, evaluations, and studies; clinical decision making; and treatment plan, in order to identify potential gaps in clinical documentation; meets established productivity targets for record review as determined by Director.
Raleigh General Hospital
Beckley, WV
Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities. A Clinical Documentation Specialist RN who excels in this role: Reviews inpatient medical records to identify missing, vague, or incomplete documentation and ensures timely resolution of provider queries.
Geisinger
Danville, PA
It is expected that the CDIS have previous clinical skills, including an understanding of Anatomy and Physiology in order to appropriately discuss with the physician such issues as the underlying etiology, principal diagnosis, diagnostic studies, treatment modalities, to name a few. The Clinical Documentation Improvement Program (CDI) is designed to improve the physician’s documentation in the patient’s medical record, supporting the appropriate severity of illness, expected risk of mortality and complexity of care of the patient.
University of California, Irvine
Orange, California
Listed among America’s Best Hospitals by U.S. News & World Report for 23 consecutive years, UCI Medical Center provides tertiary and quaternary care and is home to Orange County’s only National Cancer Institute-designated comprehensive cancer center, high-risk perinatal/neonatal program and American College of Surgeons-verified Level I adult and Level II pediatric trauma center, gold level 1 geriatric emergency department and regional burn center. *Misconduct Disclosure Requirement: As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer.
Exceptional Healthcare Inc.
Dallas, TX
In this role, you'll partner directly with physicians, nurses, and coders to ensure clinical documentation tells the full story — capturing the true severity of illness, the complexity of care delivered, and the outcomes that matter. This isn't a back-office job — you'll be rounding with physicians, shaping how care is captured, and making a measurable impact on quality and revenue.
HCA Healthcare
$43.28 - $64.94
Campbell, CA
Must hold at least one of the following credentials: Certified Risk Adjustment Coder (CRC®), Certified Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Professional Coder (CPC®), Certified Coding Specialist (CCS), Certified Coding Specialist[1]Physician (CCS-P), RHIT (Registered Health Information Technician), RHIA (Registered Health Information Administrator). Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.
Penn Medicine
Philadelphia, PA
Active participation in team meetings and educational presentations to CDI Specialists, Coders, various Physician groups and others on specific documentation improvement topics. Provide individual and group education to Coding staff, Clinical Documentation Improvement (CDI) Specialists, Providers and others throughout the organization that requires coding and documentation knowledge.
UF Health
Leesburg, Florida
Performs concurrent and retrospective second-level reviews for identified opportunities and retrospective requests, including but not limited to: Low-acuity discharges to hospice and mortalities. Develops and recommends strategic approaches and process refinements to optimize opportunity capture within the CDS team, including prioritization and assignment based on retrospective requests and second-level reviews.
Sarasota Memorial Health Care System
Sarasota, Florida
The Specialist is also responsible for querying physicians on specificity of diagnosis or procedures performed in order to ensure the account appropriately reflects the patient’s Severity of Illness (SOI), Risk of Mortality (ROM), and resources used to care for the patient resulting in complete and accurate profiling and reporting outcomes. Job Summary: The Clinical Documentation Integrity Specialist is responsible for facilitating the improvement and overall quality and completeness of clinical documentation to support coding and will be responsible for reviewing medical records including daily admissions while the patient is still in-house (concurrent), as well as, subsequent reviews until discharge.
Sarasota Memorial Health Care System
Sarasota, Florida
Job Summary: The Post-Acute Clinical Documentation Integrity Specialist is responsible for facilitating the improvement in the overall quality and completeness of clinical documentation to support coding in the post-acute inpatient setting, and will be responsible for reviewing daily new admission inpatient post-acute medical records, as well as, subsequent reviews while patient is still in-house (concurrent) until discharged. - Prefer knowledge of Prospective Payment System methodology in area of hire (Skilled Nursing Facility Prospective Payment System - Patient Driven Payment Model (PDPM); Inpatient Rehabilitation Facility – Case Mix Group (CMG); Long Term Care Hospital – MS-LTC-DRG).
Atlantic Health System
Morristown, NJ
Atlantic Medical Group, comprised of 1,000 physicians and advanced practice providers, represents one of the largest multi-specialty practices in New Jersey and includes finance, legal, marketing, human resources, talent acquisition, ISS and more. Serves as a member of the facility CDI Team and Documentation Improvement Work Group, providing input relative to documentation improvement processes and resources, and updates corporate HIM on facility coding/documentation improvement efforts .
Vanderbilt University Medical Center
Nashville, TN
Discover Vanderbilt University Medical Center : Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery, and patient care, VUMC is a community of individuals who come to work each day with the simple aim of changing the world. - Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them.
Ansible Government Solutions
Orlando, FL
Ansible Government Solutions, LLC (Ansible) is seeking multiple Registered Nurse Clinical Documentation Improvement (CDI) Specialists to work with us in support of the Orlando VA Medical Center located at 13800 Veterans Way Orlando, FL 32827. Serve as the CDI Registered Nurse Advisor (RNA), applying nursing and clinical judgment to validate diagnoses, procedures, severity of illness (SOI), and risk of mortality (ROM).
Moffitt Cancer Center
Tampa, Florida
The Clinical Documentation Specialist Senior assesses clinical documentation through extensive medical record review, deployment of artificial intelligence, and collaborating directly with the providers to clarify the documentation to accurately and completely reflect the patients’ medical conditions. Extensive collaboration with physicians, mid-levels, nursing staff, other patient care givers to include developing and delivering education, which will be accomplished with on-site meetings, zoom meetings, telephonic discussions, rounding and email.
NOR Healthcare Systems
Norwalk, CA
The CDI Specialist Level II is responsible for conducting clinically based concurrent and retrospective reviews of inpatient medical records to evaluate if clinical documentation is reflective of medical necessity, quality of care outcomes and reimbursement compliance for acute care services provided. Reviews inpatient medical records, meeting all department productivity goals, for identified payor populations as directed on admission and throughout hospitalization and identifies potential gaps in physician documentation.
Greenberg-Larraby, Inc. (GLI)
Memphis, TN
As a Clinical Documentation Integrity Specialist (CDIS) at Greenberg-Larraby, Inc. (GLI), you will play a vital role in ensuring the accuracy and completeness of clinical documentation within the healthcare facility in Memphis. You will collaborate with physicians and healthcare providers to improve patient care quality by enhancing clinical documentation that supports coding accuracy and reflects the true severity of illness.
Memorial Health
Springfield, Illinois
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. Previous clinical documentation experience strongly preferred with experience in assigning DRGs based on clinical documentation to facilitate reimbursement from admissions, and preparing supporting correspondence or appeal letters as needed.
The University of Chicago Medicine
Chicago, Illinois
The CDS obtains appropriate clinical documentation through collaborative communications from having developed positive working relationships with physicians, nursing staff, other patient care providers, and the Health Information Management Department Coders. In this role, the Clinical Documentation Specialist - Inpatient promotes modifications to medical record documentation to ensure accurate depiction of the level of clinical services provided to the patient and to completely describe patients’ severity of illness.
Geisinger
Danville, PA
Promotes a partnership with the inpatient coding professionals to ensure the accuracy of principal diagnosis, procedures and completeness of supporting documentation to determine the working and final DRG, severity of illness and risk of mortality. It is expected that the CDIS have previous clinical skills, including an understanding of Anatomy and Physiology in order to appropriately discuss with the physician such issues as the underlying etiology, principal diagnosis, diagnostic studies, treatment modalities, to name a few.
Intermountain Health
$35.25 - $54.39
Helena, MT
The Clinical Documentation Specialist ensures clinical documentation is accurate, consistent, compliant, and specific through the performance of reviews and initiation of queries to providers to achieve appropriate ICD-10 code and DRG (Diagnosis Related Groups) assignment for each patient. Acute care includes medical/surgical or similar experience integrating knowledge of pathophysiology and acute care and disease management, physical assessment, clinical evaluation and monitoring with best practice treatment modalities for inpatient hospital populations (excluding rehab, psych).
Pediatric Home Service
Houston, TX
This role maintains supporting documentation databases, manages insurance and physician orders, and provides operational support to clinical areas to promote seamless care delivery and regulatory compliance. High school diploma or GED required; One year of related experience/training preferred (intake, documentation or clinical support); Or equivalent combination of education and experience.
The University of Chicago Medicine
LaGrange, IL
The CDS obtains appropriate clinical documentation through collaborative communications from having developed positive working relationships with physicians, nursing staff, other patient care providers, and the Health Information Management Department Coders. Works closely with HIM coding staff to assure documentation of principal diagnosis and any co-existing comorbidities and complications accurately reflect the patient’s clinical status and level of services provided.
Memorial Healthcare
Owosso, MI
Ability to interact with co-works, hospital staff, administration, patients, physicians, the public and all internal and external customers in a professional and effective, courteous and tactful manner, at all time, physically, verbally and in all written and electronic communication. (b) Same‑Day Surgery CDI focuses on ensuring documentation for ambulatory surgical procedures is accurate, capture diagnosis to the highest specificity, supports medical necessity, and clearly reflects the procedure performed.
Doctors Medical Center of Modesto
Modesto, CA
Reporting to the Manager, CDI (Corporate), the Clinical Documentation Specialist (CDS) will be responsible for facilitating concurrent documentation of the medical record to achieve accurate inpatient coding and legitimate DRG assignment. Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance.
Valley Children's Healthcare
$26.65 - $37.9
Madera, CA
Our family-centered, pediatric services extend from a leading pediatric cancer and blood disorders center home on the West Coast, and a pediatric heart center known for its expertise and pioneering treatments, to a Regional Level IV neonatal intensive care unit (NICU), the highest level referral center between Los Angeles and the Bay Area. Our network offers highly specialized medical and surgical services to care for children with conditions ranging from common to the highly complex at our 358-bed stand-alone childrens hospital that includes 28 regional NICU beds.
Baptist Memorial Health Care
Jackson, MS
Must demonstrate knowledge of the principles of disease definitions and natural history, possess the ability to assess data reflective of the patient's clinical status, interpret the appropriate information needed to identify each patient's acuity and severity of illness. Improves documentation specificity, and acuity by educating physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay.
Baptist Memorial Health Care
Memphis, TN
Must demonstrate knowledge of the principles of disease definitions and natural history, possess the ability to assess data reflective of the patient's clinical status, interpret the appropriate information needed to identify each patient's acuity and severity of illness. Improves documentation specificity, and acuity by educating physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay.
Customer Value Partners
Memphis, Tennessee
CVP is an award-winning healthcare and next-gen technology and consulting services firm solving critical problems for healthcare, national security, and public sector clients. Certification from American Health Information Management Association (AHIMA) and/or American Academy of Professional Coders (AAPC) and/or Association of Clinical Documentation Integrity Specialists (ACDIS).
Piedmont Healthcare Inc.
Atlanta, Georgia
Responsibilities: Reviewing clinical documentation to facilitate the accurate representation of the severity of illness, expected risk of mortality, and complexity of care by improving the quality of the physician's clinical documentation. Previous clinical documentation improvement experience, utilization management, precertification, coding, Medicare regulations, quality assurance, or related area Preferred.
Infirmary Health
Mobile, Alabama
Responsibilities: Improves overall quality and completeness of clinical documentation by performing concurrent review of the medical record to achieve accurate inpatient coding and a working DRG assignment. Identifies process improvement opportunities and supports the timely and accurate capture of measurements to improve patient outcomes.
Central Maine Medical Center
LEWISTON, Maine
Other system services include the Central Maine Heart and Vascular Institute, a regional trauma program, LifeFlight of Maine's southern Maine base, the Central Maine Comprehensive Cancer Center and other high-quality clinical services. Other responsibilities include conducting documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings.
CORPORATE
Mount Kisco, NY
Facilitates modifications to clinical documentation to ensure accurate depiction of the level of clinical services and patient severity through extensive concurrent interaction with physicians, nursing staff and other caregivers, case management and medical records coding staff. Reviews clinical documentation and facilitates modifications, as needed, to ensure that documentation accurately reflects the level of service rendered and severity of illness (in compliance with government and other regulations) for all patients.
Beth Israel Lahey Health
Boston, MA
The Clinical Documentation Improvement (CDI) Specialist Registered Nurse (RN) assists with the appropriate identification of diagnoses, conditions, and/or procedures that are representative of the patient’s hospital stay and care provided including Severity of Illness (SOI), Risk of Morality (ROM), during an inpatient hospitalization. CDI Specialist RN initiates concurrent queries to providers as supported by medical record documentation to improve the accuracy, integrity, and quality of patient data, and drive improvement toward quality physician documentation within the body of the medical record.
Beth Israel Lahey Health
Charlestown, MA
The Clinical Documentation Improvement (CDI) Specialist Registered Nurse (RN) assists with the appropriate identification of diagnoses, conditions, and/or procedures that are representative of the patient’s hospital stay and care provided including Severity of Illness (SOI), Risk of Morality (ROM), during an inpatient hospitalization. CDI Specialist RN initiates concurrent queries to providers as supported by medical record documentation to improve the accuracy, integrity, and quality of patient data, and drive improvement toward quality physician documentation within the body of the medical record.