POSITION SUMMARY:

Primary responsibility is to facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, nurses, case managers, coders and other health care team members, the Clinical Documentation Integrity Specialist (CDIS), will strive to ensure comprehensive medical record documentation that reflects patients’ clinical treatment, decisions, and diagnosis. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assisting with education and training related to improving clinical documentation. This position will actively participate in educating appropriate hospital and medical staff about ICD-10.

QUALIFICATIONS:

Education, Training and Experience:

1. Associate or Bachelor degree from an accredited school of nursing, Health Information Management, and/or medicine or healthcare undergraduate/graduate degree. Masters Degree is preferred but not required
2. 3-4 years clinical experience (i.e. inpatient, clinical documentation, and/or case management reviews). Prior Clinical Documentation Improvement experience preferred. Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Documentation Improvement CDI Practitioner or completion within two years of employment.

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