The Clinical Documentation Specialist (CDS) provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation of acute care services. Includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. Improves the overall quality and completeness of clinical documentation by working closely with providers and the application of coding guidelines, evidence-based knowledge, analysis, in-depth review, interpretation, identification of opportunities, communication, and consistent follow-up and evaluation of concurrent and retrospective (as required) medical record documentation.


Essential Duties:

+ Identifies his/her respective service line(s) admissions in the CDI software/tool; and prioritizes reviews by age and payer. Completes his/her assignments by the end of the day

+ Conducts new inpatient admissions reviews and proper wor...