Key Responsibilities:

• Review medical records to ensure accurate and complete clinical documentation

• Collaborate with physicians and healthcare teams to clarify diagnoses and procedures

• Ensure compliance with coding guidelines and healthcare regulations

• Support accurate reimbursement and quality reporting initiatives

• Identify documentation improvement opportunities and provide recommendations

Qualifications:

• Bachelor's degree in Nursing

• Certification minimum requirement – Must be a Registered Nurse with CCDS and/or CDIP certification

• Minimum of 3 years of hospital bedside experience

• At least 3 years of experience in clinical documentation improvement role (CDI) - adult acute care experience in med/surg, critical care, emergency, or PACU

• Clinic Fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems