Clinical Documentation Integrity Specialist I

General Summary

Responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. Assists treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of services rendered. Assesses clinical documentation through extensive review of the medical record, interaction with providers, nursing staff, other patient care givers, and Health Information Management (HIM) 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.