Clinical Documentation Integrity Specialist

Full-time IT & Technology

Job Purpose

The Clinical Documentation Integrity Specialist focuses on the accuracy, completeness and consistency of inpatient clinical documentation to support coding and reporting of high-quality healthcare data. The Clinical Documentation Integrity Specialist performs concurrent chart reviews to validate that the clinical documentation in the medical record appropriately describes the patient’s severity of illness, complexity of care, and risk of mortality to facilitate appropriate coding. The Clinical Documentation Integrity Specialist utilizes advanced knowledge of disease processes, medications, and critical thinking to analyze current documentation to identify gaps in clinical documentation.

Duties & Responsibilities

• Analyze medical records to identify incomplete, inconsistent, or inaccurate documentation related to diagnoses, treatments, procedures, severity of illness, and risk of mortality
• Perform concurrent chart reviews to ensure...