Clinical Documentation Excellence Specialist

Joint Township District Memorial Hospital; St. Marys (GA); On-site; USD 70,000 - 100,000; Full time

Job summary

Grand Lake Health System is seeking a Certified Documentation Specialist to review and improve clinical documentation across patient records in alignment with ICD and CPT guidelines.

The role involves concurrent reviews, educating providers, and ensuring documentation supports appropriate reimbursement and patient severity. Collaboration with physicians, nursing staff, and coding teams is essential to enhance audit readiness and care quality.

Qualifications

• Associate’s degree in Healthcare or related field required; training in medical terminology, anatomy, and physiology.
• Must have training and certification in coding, or equivalent combination of education & experience.
• Three to five years CDI experience preferred.
• In-depth knowledge of medical record content and ICD & CPT guidelines.
• Experience with compliant healthcare documentation and HCC coding requirements.

Responsibilities

• Core documentation review for completeness, specificity, and compliance with coding guidelines.
• Inpatient coding and compliance: link documentation to ICD and CPT codes and assess medical necessity; provide guidance on documentation improvement opportunities.
• Risk adjustment and quality reporting: understand documentation requirements for HCC and support accurate reporting for quality initiatives and value-based care.
• Communication and provider education: provide feedback to providers on documentation deficiencies and educate clinicians on best practices; enhance collaboration between coding, billing and clinical staff.

Skills

Observation skills

Analytical thinking

Problem solving

Verbal communication

Written communication

Presentation skills

Interpersonal skills

Education

Associate’s degree in Healthcare or related field

Tools

Coding encoders

Job description

Grand Lake Health System is seeking a Certified Documentation Specialist to review and improve clinical documentation across patient records in alignment with ICD and CPT guidelines.

The role involves concurrent reviews, educating providers, and ensuring documentation supports appropriate reimbursement and patient severity. Collaboration with physicians, nursing staff, and coding teams is essential to enhance audit readiness and care quality.