• Clinical Documentation Improvement Specialist

    Job ID
    Employment Type
    Hours Per Week
    Onsite Work Schedule Details
    M-F 8AM-4PM, this is not a REMOTE position
    6300 Main St
  • 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.


    • Obtains 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.
    • Facilitates appropriate clinical documentation to ensure that level of services and acuity of accurately reflected in the medical record.
    • Uses 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.
    • Processes discharges by updating the Severity/Complexity of Services Worksheet to reflect any changes in status, procedures/treatments, and conferring with physician to finalize diagnosis.
    • Educates 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.
    • Participates in patient care conference/case conferences to identify needs for clinical documentation.
    • Generates accurate reports for the client upon the close of each phase of an engagement.
    • Supports nThrive’s Compliance Program by adhering to policies and procedures pertaining to HIPAA, FDCPA, FCRA, and other laws applicable to nThrive’s business practices. This includes: becoming familiar with nThrive’s Code of Ethics, attending training as required, notifying management or nThrive’s Helpline when there is a compliance concern or incident, HIPAA-compliant handling of patient information, and demonstrable awareness of confidentiality obligations.


    • Associate degree.
    • Active RN, CCDS or CDIP credential.
    • 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.
    • Knowledge of medical terminology, ICD-10-CM and CPT-4 codes.
    • Knowledge of CDI strategies.

    About nThrive

    Be Inspired. Ignite Change. Transform Health Care.
    From Patient-to-Payment, 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.


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