• Clinical Documentation Improvement Specialist

    Job ID
    Employment Type
    Hours Per Week
    Onsite Work Schedule Details
    M- F
    329 A Adair Street
  • Overview

    The Clinical Documentation Improvement Specialist is responsible for performing concurrent review of the clinical documentation in order to ensure compliant, appropriate and accurate reimbursement.  Analyzes documentation of the clinical status of patients. Collaborates with coding staff to ensure documentation of diagnoses.


    • Obtain appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers, and Health Information Management coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate.
    • Facilitate appropriate clinical documentation to ensure that level of services and acuity of accurately reflected in the medical record.
    • Use your extensive knowledge of documentation requirements and guidelines in accordance with Coding Clinic to improve the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation guidelines.
    • Process discharges by updating the Severity/Complexity of Services Worksheet to reflect any changes in status, procedures/treatments, and conferring with physician to finalize diagnosis.
    • Educate internal staff on clinical documentation guidelines and conduct follow up reviews of clinical documentation to ensure points clarified with the physician have been recorded in the patient’s record. Reviews clinical issues with the coding staff to assign a working DRG.
    • Participate in patient care conference/case conferences to identify needs for clinical documentation.
    • Generate accurate reports for the client upon the close of each phase of an engagement.


    • 2+ years of clinically well-rounded medical or surgical acute care/inpatient nursing experience.
    • RN licensure
    • Knowledge of medical terminology, ICD-9-CM and CPT-4 codes.


    Preferred Skills


    • Critical care nursing experience.
    • Knowledge of clinical documentation guidelines and CDI program implementation experience.
    • Knowledge of CDI strategies

    About nThrive

    Be Inspired. Ignite Change. Transform Health Care. 

    From Patient-to-PaymentSM, nThrive provides all the technology, advisory expertise, services, analytics and education programs health care organizations need to thrive in the communities they serve. Our colleagues share a united passion to help health care organizations strengthen their financial position, which translates to accessible, quality care for all. This passion fuels our drive to innovate and participate in community outreach through the nThrive CARES program. Our colleagues are encouraged to think differently and empowered to make a lasting impact that ensures our health care providers, and our world, are healthy and productive.#LI-SS1


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