Clinical Documentation Improvement Specialist

Job ID
Employment Type
Hours Per Week


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.


  • Knowledge of medical terminology, ICD-9-CM and CPT-4 codes.
  • Knowledge of CDI strategies

Preferred Skills

  • Associate’s Degree in a relevant field  or combination of equivalent education and experience.
  • RN, CCDS or CDIP
  • 3+ years of clinically well-rounded medical or surgical acute care nursing experience.
  • Critical care nursing experience.
  • Knowledge of clinical documentation guidelines and CDI program implementation experience.

About nThrive

nThrive is the leader in providing end-to-end revenue cycle services, technology and education solutions. Previously known as MedAssets, Precyse, Equation and Adreima, each formerly a leader in its own right, we’ve combined our talents and capabilities into a single enterprise. At nThrive, we are people who are passionate about empowering health care for every one in every community. We work together to transform financial and operational performance, enabling health care organizations to thrive.
nThrive is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, age, veteran status, disability, national origin, sex, sexual orientation, religion, gender identity or any other federal, state or local protected class.


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