What does a clinical documentation improvement specialist do?
Clinical documentation improvement specialists are professionals who are involved in the clinical documentation improvement (CDI) program that incorporates the terminology needed to translate a patient's condition into precise codes. These specialists must investigate complex healthcare reimbursement information to ensure that appropriate documentation is provided for proper patient care. They must collaborate with physicians and medical record coding staff so that they facilitate the clinical documentation improvement process. Clinical documentation improvement specialists must also train members of the patient care team about the documentation guidelines for medical records.
Clinical documentation improvement specialist responsibilities
Here are examples of responsibilities from real clinical documentation improvement specialist resumes:
- Create documentation education classes to general surgery residents, increasing the leveling of reporting which lead to increase revenues.
- Interact directly with physicians to query for more specific documentation and to provide documentation guidelines from ICD-9 and ICD-10 standards.
- Prepare, maintain and update clinical documentation ensuring completeness and accuracy of services provide to the patients.
- Assign the correct POA status.
- Participate in the initiation of the CDIS program.
- Train new employees on how to utilize radiology information systems.
- Partner with coding professionals to determine a working and final MS-DRG.
- Target post-discharge and specialty line chart audits / documentation and MS-DRG assignment reviews.
- Develop strategic enhancements to assist in daily use of EMR and clinic flow.
- Generate queries for clarification or quality of the documentation and for MCCs, CCs.
- Request documentation clarification as appropriate for SOI, ROM, POA, and VBP.
- Travele to various offices, working remotely, on various EMR / EHR systems.
- Form queries per AHIMA practice rules/guidelines as needed for clarification, specificity, precision, etc.
- Gather all information need for MDS including all responsible sections of the MDS and interviews require.
- Educate coders in the diagnoses, treatments and procedures to which they assign ICD-10-CM and CPT codes.
Clinical documentation improvement specialist skills and personality traits
We calculated that 18% of Clinical Documentation Improvement Specialists are proficient in Patients, Patient Care, and Clinical Documentation Improvement. They’re also known for soft skills such as Analytical skills, Detail oriented, and Integrity.
We break down the percentage of Clinical Documentation Improvement Specialists that have these skills listed on their resume here:
- Patients, 18%
Validated diagnostic codes and identified any missing diagnosis to ensure patients severity of illness was accurately reflected in the medical record.
- Patient Care, 13%
Provided formalized education session for all members of the interdisciplinary patient care staff regarding clinical documentation opportunities and coding reimbursement issues
- Clinical Documentation Improvement, 12%
Worked collaboratively with physicians, medical record coding staff, and interdisciplinary teams to facilitate the clinical documentation improvement process.
- CCDS, 8%
Obtained CCDS certification in 2016.
- ICD-10, 7%
Interacted directly with physicians to query for more specific documentation and to provide documentation guidelines from ICD-9 and ICD-10 standards.
- CCS, 6%
Generated queries for clarification or quality of the documentation and for MCCs, CCs.
Common skills that a clinical documentation improvement specialist uses to do their job include "patients," "patient care," and "clinical documentation improvement." You can find details on the most important clinical documentation improvement specialist responsibilities below.
Analytical skills. To carry out their duties, the most important skill for a clinical documentation improvement specialist to have is analytical skills. Their role and responsibilities require that "health information technicians must understand and follow medical records and diagnoses, and then decide how best to code them in a patient’s medical records." Clinical documentation improvement specialists often use analytical skills in their day-to-day job, as shown by this real resume: "prepare and present analytical reports of clinical documentation improvements monitoring to hospital leadership"
Detail oriented. Another essential skill to perform clinical documentation improvement specialist duties is detail oriented. Clinical documentation improvement specialists responsibilities require that "health information technicians must be accurate when recording and coding patient information." Clinical documentation improvement specialists also use detail oriented in their role according to a real resume snippet: "detailed review of all clinical documentation for completeness, appropriateness, inter-relationships. "
Integrity. clinical documentation improvement specialists are also known for integrity, which are critical to their duties. You can see how this skill relates to clinical documentation improvement specialist responsibilities, because "health information technicians work with patient data that are required, by law, to be kept confidential." A clinical documentation improvement specialist resume example shows how integrity is used in the workplace: "audit paper and electronic claims data to ensure data integrity. "
Interpersonal skills. clinical documentation improvement specialist responsibilities often require "interpersonal skills." The duties that rely on this skill are shown by the fact that "health information technicians need to be able to discuss patient information, discrepancies, and data requirements with other professionals such as physicians and finance personnel." This resume example shows what clinical documentation improvement specialists do with interpersonal skills on a typical day: "cited for excellence in interpersonal communications, teamwork, customer service, flexibility and reliability. "
Technical skills. Another common skill required for clinical documentation improvement specialist responsibilities is "technical skills." This skill comes up in the duties of clinical documentation improvement specialists all the time, as "health information technicians must use coding and classification software and the electronic health record (ehr) system that their healthcare organization or physician practice has adopted." An excerpt from a real clinical documentation improvement specialist resume shows how this skill is central to what a clinical documentation improvement specialist does: "provide cms, or other contractor, clinical and technical support in convening committees, and workgroups. "
The three companies that hire the most clinical documentation improvement specialists are:
- Geisinger Medical Center14 clinical documentation improvement specialists jobs
- Community Health Systems5 clinical documentation improvement specialists jobs
- UnitedHealth Group4 clinical documentation improvement specialists jobs
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Compare different clinical documentation improvement specialists
Clinical documentation improvement specialist vs. Records manager
The records manager is an important position that handles the creation, organization, and disposal of records. They are also responsible for establishing systems for their management and the maintenance, verification, and evaluation of extant systems. It will require technical and analytical skills, as well as a great deal of integrity for handling sensitive information.
These skill sets are where the common ground ends though. The responsibilities of a clinical documentation improvement specialist are more likely to require skills like "patients," "patient care," "clinical documentation improvement," and "ccds." On the other hand, a job as a records manager requires skills like "office equipment," "access database," "sharepoint," and "dod." As you can see, what employees do in each career varies considerably.
Records managers earn the highest salaries when working in the professional industry, with an average yearly salary of $58,862. On the other hand, clinical documentation improvement specialists are paid more in the health care industry with an average salary of $70,124.The education levels that records managers earn slightly differ from clinical documentation improvement specialists. In particular, records managers are 2.3% less likely to graduate with a Master's Degree than a clinical documentation improvement specialist. Additionally, they're 6.5% less likely to earn a Doctoral Degree.Clinical documentation improvement specialist vs. Records analyst
A records analyst is responsible for maintaining the security and efficiency of record management processes for storing information and files in the database. Records analysts review documents and sort data accordingly, following organizational procedures in proper disposal of outdated documents. They also update client accounts and business information in the system, managing retention schedules, and strategizing effective data management techniques. A records analyst must have excellent knowledge of computer navigation, especially in using software applications for filing and coding data.
In addition to the difference in salary, there are some other key differences worth noting. For example, clinical documentation improvement specialist responsibilities are more likely to require skills like "patients," "patient care," "clinical documentation improvement," and "ccds." Meanwhile, a records analyst has duties that require skills in areas such as "data entry," "powerpoint," "sharepoint," and "retention schedules." These differences highlight just how different the day-to-day in each role looks.
On average, records analysts earn a lower salary than clinical documentation improvement specialists. Some industries support higher salaries in each profession. Interestingly enough, records analysts earn the most pay in the professional industry with an average salary of $54,922. Whereas clinical documentation improvement specialists have higher pay in the health care industry, with an average salary of $70,124.In general, records analysts achieve similar levels of education than clinical documentation improvement specialists. They're 4.0% less likely to obtain a Master's Degree while being 6.5% less likely to earn a Doctoral Degree.Clinical documentation improvement specialist vs. Recording technician
A recording technician specializes in operating audio systems and equipment for various purposes such as recordings, broadcasts, and events. It is their responsibility to prepare equipment according to project or program requirements like microphones, audio lines, speakers, and amplifiers, ensuring everything is accounted for and is functioning efficiently. Aside from setting up equipment, they must also conduct regular maintenance checks and perform repairs as necessary. Moreover, as a recording technician, it is essential to maintain an active communication line with staff for a smooth and efficient workflow.
Some important key differences between the two careers include a few of the skills necessary to fulfill the responsibilities of each. Some examples from clinical documentation improvement specialist resumes include skills like "patients," "patient care," "clinical documentation improvement," and "ccds," whereas a recording technician is more likely to list skills in "customer service," "data entry," "database systems," and "office equipment. "
Recording technicians make a very good living in the government industry with an average annual salary of $38,663. On the other hand, clinical documentation improvement specialists are paid the highest salary in the health care industry, with average annual pay of $70,124.Most recording technicians achieve a lower degree level compared to clinical documentation improvement specialists. For example, they're 8.4% less likely to graduate with a Master's Degree, and 7.4% less likely to earn a Doctoral Degree.Clinical documentation improvement specialist vs. Records coordinator
A records coordinator takes responsibility for doing administrative and clerical work. Records coordinators maintain the filing system of the central records. They monitor, post, and process university forms for personnel and budgetary actions. It is their job to maintain an organized central filing system. They must know the requirements applicable to their organization. There are certain skills every records coordinator should acquire. Some of them are skills in procurement management, organizational, negotiation, finance and accounting, and analytical.
Types of clinical documentation improvement specialist
Updated January 8, 2025
