Senior Clinical Documentation Specialist

Manages high-complexity cases, leads key initiatives, and serves as a subject matter expert and mentor within the Clinical Documentation Integrity (CDI) departments across markets. Demonstrates expertise in CDI practices, coding guidelines, and provider collaboration to facilitate complete and accurate medical record documentation.

• Responsibilities: Facilitates clinical documentation to support diagnosis capture and to ensure the level of service rendered to patients is accurately recorded and reflected in the medical record.
• Provides expert analysis of medical record documentation for symptoms and clinical indicators to identify potential primary/secondary diagnoses and complications.
• Initiates and maintains interactions with physicians and advanced practice providers to address the need for more detailed information in the medical record. Formulates and distributes physician documentation clarification queries following coding guidelines and applicable compliance standards.
• Participates in quality improvement projects aimed at documentation practices and ensuring compliance with regulatory standards.
• Serves as a subject matter expert in clinical documentation and coding guidelines. Shares knowledge and expertise with colleagues and stakeholders.
• Utilizes knowledge of clinical complications, co-morbidities, severity of illness, risk of mortality, case mix index, secondary diagnosis, and impact of procedures on the final diagnosis related group (DRG) to complete CDI work.

Licensure / Certification / Registration

• Required Credential(s):
  • Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.

Education

• High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree with 1 year of experience OR 5 years of applicable cumulative job specific experience required. 2 years of leadership or management experience preferred.