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Clinical Documentation Improvement Specialist

Clinical documentation improvement specialists perform/handle the following responsibilities/tasks:

To facilitate improvement in the quality, accuracy and completeness of medical records documentation, the clinical documentation improvement specialists perform the following tasks

  • Analyzes clinical information through medical records
  • Evaluates discharge diagnoses, runs reports, and identifies any discrepancies or opportunities for improvement
  • Follows through with personnel from all disciplines, and develop education programs to assist them in the future

Note: Some of these responsibilities may apply depending on experience and the nature of environment.

Salary Range

  • The average annual salary is $60,000 which can vary greatly due to company, location, industry, experience and benefits

Certification Needed

  • Should have completed an AHIMA approved coding program
  • Or undergone a coding training which includes anatomy and physiology, medical terminology, basic ICD diagnostic/procedural and basic CPT coding
  • CCDS certification preferred

Additional qualifications

  • Organizational, analytical and interpersonal skills
  • Ability to work with various medical professionals like specialists, hospital leadership, physicians, coders, and other members of the healthcare teams
  • Knowledge of Medicare Part A & B and other regulatory/reimbursement criteria are essential
  • Sound organization and prioritization skills
  • Sound verbal and written communication skills
  • Working experience with EMR, databases, spreadsheets and presentation programs
  • Clinical experience -- ideally in medical/surgical, acute or critical care— that leads to knowledge of the disease process

Work Environment and Outlook

  • A clinical documentation specialist may work in hospitals, clinics, nursing homes
  • According to industry sources, there is going to be a growth of 21 percent from 2010 to 2020
  • An associate's degree or less may be required for entry-level openings
Clinical documentation improvement specialists can post their details with us to access the best opportunities across all US states and varied specialties.
If your hospital or clinic needs clinical documentation improvement specialists, register your details with us and we can get one in your specialty or location preference.

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