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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

  • $37,110

    Average Salary

What Does A Clinical Documentation Improvement Specialist Do At Community Health Systems

* Knowledge of medical terminology, disease processes and clinical competency is required to ensure success in performing job duties.
* The candidate must also possess a thorough knowledge of documentation requirements and coding guidelines.
* Individual must demonstrate data quality and integrity skills.
* Ensures improved documentation to support appropriate coding, reimbursement and quality data.
* Develops and presents basic, intermediate and advanced education for CHS personnel, as follows:
* DRGs and the IPPS
* Clinical documentation improvement goals and activities
* CDI program education and query practices
* Works with hospital or corporate physician liaisons to improve physicians understanding of documentation needs for inpatient care.
* Provides documentation/coding workshops as necessary.
* Possesses an excellent understanding of coding practices, official coding guidelines and federal regulations.
* Keeps abreast of regulatory changes related to inpatient coding and documentation, and communicates these changes to appropriate corporate and hospital staff.
* Maintains a broad knowledge of the clinical aspects of diagnoses, treatment, pharmacology and procedures.
* Maintains auditing skills for documentation quality.
* Possesses the ability to develop and present effective education utilizing a variety of media platforms
* Ability to track and report documentation improvement activities
* Travels to CHS facilities to assist with CDI staffing, education or program development
* Performs remote medical record reviews as necessary
* Completes other duties, as assigned

What Does A Clinical Documentation Improvement Specialist Do At Duke University

* Through interaction with physicians, nursing staff, medical records coding staff/compliance specialists and other healthcare providers, clinical documentation analysts facilitate modifications to clinical documentation ensuring accurate depiction of the level of clinical services, reason for admission, patient severity, risk of mortality, severity of illness and conditions present on admission.
* Review medical record documentation for quality and possess ability to convey deficiencies to house staff and attending physician for resolution.
* Compile and document chart findings in dedicated CDI database on a daily basis.
* Communicate with and educate members of the patient care team (physicians and advanced practice providers) and others on the clinical documentation concepts on an ongoing basis.
* Participation on select committees and providing educational programs as necessary.
* This position may also be responsible for reviewing overall quality and completeness of coding by reconciling differences in the MS
* DRG assignment through comparison and analysis of the coding summary and CDI patient summary against medical record documentation.
* You will utilize current CMS coding guidelines, conventions and AHA coding clinics to accurately determine the principal and secondary diagnoses and procedures that affect the MS
* DRG assignment.
* You will also communicate with coders, compliance specialists and/or clinical documentation analysts regarding documentation clarification and accurate coding.
* Location:
* Durham
* Exempt/Non
* Exempt:
* Exempt
* Requisition Number:
* Position Title:
* Shift:
* First/Day
* Job Family Level:
* G1
* Full Time / Part Time:
* Regular / Temporary:
* Regular
* Department Name:

What Does A Clinical Documentation Improvement Specialist Do At South Nassau Communities Hospital

* Clinical Documentation Improvement is responsible for improving the overall quality and completeness of clinical documentation.
* Facilitates modifications to clinical documentation through extensive concurrent interaction with physicians, nursing staff, other patient caregivers and medical records coding staff to support that appropriate reimbursement and clinical severity is captured for the level of service rendered.
* Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.
* Educates all members of the patient care team on an ongoing

What Does A Clinical Documentation Improvement Specialist Do At Unitedhealth Group

* This full-time position provides CDI support to the Arizona/ Nevada Service Area Team by filling in when CDIS specialists are on paid time off/ leave, or when census at a particular hospital is higher than expected.
* The CDI specialist will be based at one of the three Dignity Health Hospitals in Arizona, and depending on the circumstance, may assist remotely from their home facility, or travel to the Arizona facility requiring assistance.
* Provides expert level review of inpatient clinical records within 24
* hours of admit

What Does A Clinical Documentation Improvement Specialist Do At Geisinger Health System

* Provides concurrent review of the clinical documentation in the medical record.
* Formulates queries via written/verbal communication when it is determined there is missing documentation, conflicting documentation or unclear documentation.
* Performs a thorough chart review to identify and capture any secondary diagnosis, or complications within the concurrent CDS tracking software for quality ratings/profiling purposes.
* Serves as an operations coordinator for the CDIS team, in addition to performing the above regular duties within the CDIS job description.
* LEAD responsibilities would include:
* Assists with the scheduling of staff for appropriate coverage
* Assists with query reconciliation and DRG mismatches with CDI/coding
* Provides feedback to Corporate CDI Director on operational concerns
* Provides feedback to Physician Advisor on provider query performance
* Provides ongoing feedback to CFO, physician leader, and administration
* Serves as a subject matter expert and authoritative resource on interpretation and application of CDI.
* Assumes personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency.
* Participates in the training of all new CDI staff, including on-going mentorship.
* Performs other duties as assigned

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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.


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.


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 jobs

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Clinical Documentation Improvement Specialist Demographics


  • Female

  • Male

  • Unknown



  • White

  • Hispanic or Latino

  • Asian

  • Unknown

  • Black or African American

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Languages Spoken

  • Spanish

  • Portuguese

  • Arabic

  • French

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Clinical Documentation Improvement Specialist

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Clinical Documentation Improvement Specialist Education

Clinical Documentation Improvement Specialist

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Top Skills for A Clinical Documentation Improvement Specialist


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Top Clinical Documentation Improvement Specialist Skills

  1. Clinical Severity
  2. Ms-Drg
  3. Secondary Diagnoses
You can check out examples of real life uses of top skills on resumes here:
  • Reviewed all inpatient records for complete and accurate documentation with regards to ICD-9 coding and MS-DRG specifications.
  • Conducted an extensive analysis of all inpatient records to evaluate documentation of principle diagnosis and all applicable secondary diagnoses.
  • Facilitated appropriate physician documentation of care delivered to reflect patient severity of illness and risk of mortality.
  • Developed and implement the Clinical Documentation Improvement Program (CDIP).
  • Utilized the query process for specificity in documentation.

Top Clinical Documentation Improvement Specialist Employers

Clinical Documentation Improvement Specialist Videos

Day in the Life of a Labor & Delivery Nurse

Medical Coder, Career Video from drkit.org

Clinical Documentation Improvement