Clinical Documentation Improvement Specialist

Job Summary:  

A Clinical Documentation Improvement Specialist is responsible for using their clinical and technical knowledge and their knowledge of medical terminology and procedures to evaluate a patient's medical record for accuracy. It’s important as part of this role to collect and update information about a patient after an appointment, including details and information about medical history and previous treatments and appointments. 

Essential Job Functions:  

• Reviews medical records and documents for a complete analysis of the patient's status 

• Ensures the accuracy of all medical documentation and establishing compliance with the Health Insurance Portability and Accountability Act (HIPAA) and other government regulations. 

• Communicates with other departments to correct missing or incorrect data and information. 

• Interprets clinical data and making sure that it's both accurate and completes by sorting and filing the required documents. 

• Stores medical documentation and validates diagnosis codes to represent different medical disorders, diseases, and symptoms. 

• Trains new staff members on different medical record-keeping policies, instructs them on how to file medical documentation, and secure it properly. 

• Enters document queries into a database and tracks reimbursements from insurance. 

Minimum Required Education, Experience & Skills  

• Associate or undergraduate degree in related field.  

• Interpersonal skills 

• Computer literacy with word processing and spreadsheet software 

• Ability to apply technical principles and concepts 

• Organized and able to work independently 

• Attention to detail 

Preferred Education, Experience & Skills 

• Certification (ex. Registered health information technician) 

• Write and speak Spanish (optional)