Qualifications

• Minimum 5 years' experience in clinical nursing, coding, or CDI-related fields.
• Bachelor's Degree in Nursing, Physician Assistant, or related healthcare field.
• Current professional license or certification in relevant area.
• Familiar with Windows-based software and basic computer skills.
• Strong knowledge of health record content, JCAHO requirements, and federal/state guidelines.

Responsibilities

• Conduct retrospective chart reviews to enhance clinical documentation completeness.
• Collaborate with physicians to address missing or conflicting documentation.
• Communicate effectively with clinicians to clarify and query documentation.
• Monitor written and verbal queries for accuracy.
• Serve as a resource for providers and coding staff on documentation best practices.
• Develop and implement CDI strategies for process improvement.
• Lead physician education initiatives to improve clinical documentation accuracy.

Benefits

• Opportunities for professional development and continuing education.
• Access to coding and clinical documentation resources and support.
• Engagement in collaborative healthcare initiatives within the organization.
• Participation in regular meetings with leadership and coding teams.
• Ability to have a significant impact on clinical documentation practices and patient care.