Clinical Documentation Improvement 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

Responsible for performing concurrent reviews of patient records to ensure complete, accurate, and specific clinical documentation. Should have a comprehensive understanding of ICD and CPT Coding Guidelines and are responsible for clarifying conflicting, incomplete, or imprecise documentation by actively seeking answers and actively educating providers.Work to continuously improve clinical documentation to best reflect the care provided and corresponding reimbursement. Responsible for improving the overall quality and completeness of clinical documentation. Facilitate modifications to clinical documentation through extensive concurrent interaction with physicians, nursing staff, other patient caregivers, and Coding staff to support that appropriate reimbursement, clinical severity of illness, and risk of mortality is captured for the level of service rendered to all patients. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and practice outcomes. Educates all members of the patient care team on an ongoing basis.DUTIES & RESPONSIBILITIES:1. Core documentation reviewAssess documentation for completeness, specificity, and compliance with coding guidelinesIdentify missing elements that impact code selection and medical necessityApply best practices for querying providers to ensure accurate documentation2. Inpatient coding and complianceLink provider documentation to ICD and CPT code assignmentReview documentation requirements, including medical necessity, provide guidance on documentation improvement opportunitiesEnsuring compliance with payer policies, NCCI edits, and federal regulations3. Risk adjustment and quality reportingUnderstand documentation requirements for HCC and risk adjustment codingSupport accurate reporting for quality initiatives and value-based careIdentify documentation gaps that affect population health and reimbursement4. Communication and provider educationProvide feedback to providers on documentation deficiencies and improvement needsEducate clinicians on best practices for supporting coding and audit readinessEnhance collaboration between coding, billing, and clinical staff to reduce denials and compliance riskQualifications:Education:Must have an Associate’s degree in Healthcare, Nursing or related field, or equivalent combination of education & experience.Must have training in medical terminology, anatomy, and physiology.Must have training and certification in coding, or equivalent combination of education and experience.Three to five years CDI experience preferred.Licensure:Must possess a certification; Certified Documentation Expert Inpatient (CDEI), Certified Clinical Documentation Specialist (CCDS), or Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) with coding or clinical documentation integrity experience.Must agree to obtain CDEI or CCDS within first year of employment.Experience:In-depth knowledge of medial record content.In-depth knowledge of coding/classification systems (ICD & CPT) and associated coding guidelines.Experience with compliant healthcare documentation, HCC coding requirements, alternate payment models in a multi-facility, revenue cycle experience.Basic computer skills.Skills:Should be knowledgeable in use of coding software (encoders).Should be knowledgeable in LDC/NCD (or how to look this up) and Quality Measures.Should be knowledgeable in coding guidelines.Requires excellent observation skills, analytical thinking, problem solving, plus excellent verbal/ written and presentation skills.Must have the ability to balance and juggle multiple tasks, projects, and requests; meet deadlines.Ability to communicate effectively via remote Teams application.Physical Effort:Manual and finger dexterity.Sitting for extended periods of time.Ambulate to provider practices or group meetings, as needed.Requires corrected vision and hearing to normal range.Requires working under stressful conditions.Interpersonal Skills:Excellent interpersonal skills in dealing with co-workers, providers, physicians and their office staff, Practice Mangers, and other Work Areas.Must have strong initiative, excellent judgment, good problem-solving skills, and excellent interpersonal skills.Develop and maintain positive working relationships among all levels of the organization to effectively develop and implement key initiatives.Grand Lake Health System provides equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state and local laws. GLHS complies with applicable state and local laws governing nondiscrimination in employment in all of our locations. In addition, Grand Lake Health System is an At-Will Employment employer.