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Become A Clinical Documentation Improvement Specialist

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Working As A Clinical Documentation Improvement Specialist

  • Getting Information
  • Processing Information
  • Documenting/Recording Information
  • Interacting With Computers
  • Organizing, Planning, and Prioritizing Work
  • Mostly Sitting

  • Repetitive

  • $74,182

    Average Salary

What Does A Clinical Documentation Improvement Specialist Do

Medical records and health information technicians, commonly referred to as health information technicians, organize and manage health information data by ensuring that it maintains its quality, accuracy, accessibility, and security in both paper files and electronic systems. They use various classification systems to code and categorize patient information for insurance reimbursement purposes, for databases and registries, and to maintain patients’ medical and treatment histories.

Duties

Health information technicians typically do the following:

  • Review patients’ records for timeliness, completeness, accuracy, and appropriateness of data
  • Organize and maintain data for clinical databases and registries
  • Track patient outcomes for quality assessment
  • Use classification software to assign clinical codes for reimbursement and data analysis 
  • Electronically record data for collection, storage, analysis, retrieval, and reporting
  • Maintain confidentiality of patients’ records

Health information technicians document patients’ health information, including their medical history, symptoms, examination and test results, treatments, and other information about healthcare services that are provided to patients. Their duties vary by employer and by the size of the facility in which they work.

Although health information technicians do not provide direct patient care, they work regularly with registered nurses and other healthcare professionals. They meet with these workers to clarify diagnoses or to get additional information to make sure that records are complete and accurate.

The increasing adaptation and use of electronic health records (EHRs) will continue to change the job responsibilities of health information technicians. Technicians will need to be familiar with, or be able to learn, EHR computer software, follow EHR security and privacy practices, and analyze electronic data to improve healthcare information, as more healthcare providers and hospitals adopt EHR systems.

Health information technicians can specialize in many aspects of health information. Some work as medical coders, sometimes called coding specialists, or as cancer registrars.

Medical coders typically do the following:

  • Review patient information for preexisting conditions, such as diabetes
  • Assign appropriate diagnoses and procedure codes for patient care, population health statistics, and billing purposes
  • Work as a liaison between the health clinician and billing offices

Cancer registrars typically do the following:

  • Review patients’ records and pathology reports to verify completeness and accuracy
  • Assign classification codes to represent the diagnosis and treatment of cancers and benign tumors
  • Conduct annual followups to track treatment, survival, and recovery
  • Compile and analyze cancer patient information for research purposes
  • Maintain facility, regional, and national databases of cancer patients

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How To Become A Clinical Documentation Improvement Specialist

Health information technicians typically need a postsecondary certificate to enter the occupation, although some may need an associate’s degree. Certification is often required.

Education

Postsecondary certificate and associate’s degree programs in health information technology typically include courses in medical terminology, anatomy and physiology, health data requirements and standards, classification and coding systems, healthcare reimbursement methods, healthcare statistics, and computer systems. Applicants to health information technology programs may increase their chances of admission by taking high school courses in health, computer science, math, and biology.

A high school diploma or equivalent and previous experience in a healthcare setting are enough to qualify for some positions, but most jobs for health information technicians require postsecondary education.

Important Qualities

Analytical skills. Health information technicians must be able to understand and follow medical records and diagnoses, and then decide how best to code them in a patient’s medical records.

Detail oriented. Health information technicians must be accurate when recording and coding patient information.

Integrity. Health information technicians work with patient data that are required, by law, to be kept confidential. They must exercise caution and a strong sense of ethics when working with this information in order to protect patient confidentiality.

Interpersonal skills. Health information technicians need to be able to discuss patient information, discrepancies, and data requirements with other professionals such as physicians and finance personnel.

Technical skills. Health information technicians must be able to use coding and classification software and the electronic health record (EHR) system that their healthcare organization or physician practice has adopted.

Licenses, Certifications, and Registrations

Most employers prefer to hire health information technicians who have certification, or they may expect applicants to earn certification shortly after being hired. A health information technician can earn certification from several organizations. Certifications include the Registered Health Information Technician (RHIT) and the Certified Tumor Registrar (CTR), among others.

Some organizations base certification on passing an exam. Others require graduation from an accredited program. Many coding certifications also require coding experience in a work setting. Once certified, technicians typically must renew their certification regularly and take continuing education courses.

A few states and facilities require cancer registrars to be licensed. Licensure requires the completion of a formal education program and the Certified Tumor Registrar (CTR) certification.

Advancement

Health information technicians may advance to other health information positions by receiving additional education and certifications. Technicians may be able to advance to a position as a medical or health services manager after completing a bachelor’s or master’s degree program and taking the required certification courses. Requirements vary by facility.

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Clinical Documentation Improvement Specialist Typical Career Paths

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Clinical Documentation Improvement Specialist Demographics

Gender

Female

82.2%

Male

15.3%

Unknown

2.5%
Ethnicity

White

62.6%

Hispanic or Latino

13.6%

Black or African American

12.4%

Asian

6.9%

Unknown

4.6%
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Foreign Languages Spoken

Spanish

50.0%

Portuguese

25.0%

Arabic

12.5%

French

12.5%
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Clinical Documentation Improvement Specialist Education

Schools

University of Phoenix

17.6%

Thomas Edison State University

5.9%

Florida International University

5.9%

Walden University

5.9%

Grand Canyon University

5.9%

University of Texas at Arlington

3.9%

College of Saint Scholastica

3.9%

Excelsior College

3.9%

Webster University

3.9%

Troy University

3.9%

Chamberlain College of Nursing-Illinois

3.9%

Wichita State University

3.9%

Kaplan University

3.9%

Broward College

3.9%

University of Cincinnati

3.9%

Ohio University -

3.9%

Cairn University

3.9%

University of South Alabama

3.9%

Western Michigan University

3.9%

Northeastern University

3.9%
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Majors

Nursing

55.0%

Health Care Administration

9.0%

Business

7.6%

Computer Information Systems

6.6%

Medicine

4.3%

Management

2.4%

Veterinary Science

2.4%

Public Health

1.4%

Health/Medical Preparatory Programs

1.4%

Nursing Science

1.4%

Education

1.4%

Physiology And Anatomy

0.9%

Family Practice Nursing

0.9%

Military Applied Sciences

0.9%

Clinical Psychology

0.9%

Public Administration

0.9%

Legal Support Services

0.9%

Apparel And Textiles

0.5%

Psychology

0.5%

Nursing Assistants

0.5%
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Degrees

Bachelors

38.7%

Masters

24.9%

Associate

20.4%

Other

7.1%

Doctorate

4.0%

Certificate

2.7%

Diploma

1.8%

License

0.4%
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Top Skills for A Clinical Documentation Improvement Specialist

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  1. CMS Ms-Drg
  2. Mortality
  3. Principal Diagnosis
You can check out examples of real life uses of top skills on resumes here:
  • Interact with physician regarding documentation appropriate to diagnosis and support appropriate levels of severity of illness and risk of mortality.
  • Identified appropriate principal diagnosis to establish a working DRG assignment and average length of stay.
  • Utilized the query process for specificity in documentation.
  • Developed and implement the Clinical Documentation Improvement Program (CDIP).
  • Provided concurrent medical record reviews for physician documentation accuracy.

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Top Clinical Documentation Improvement Specialist Employers

Jobs From Top Clinical Documentation Improvement Specialist Employers

Clinical Documentation Improvement Specialist Videos

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Medical Coder, Career Video from drkit.org

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