Clinical Coding & Documentation Specialist

Job Summary

We are looking for a Clinical Documentation Improvement (CDI) Specialist responsible for ensuring accurate, complete, and compliant inpatient clinical documentation to support coding accuracy, reimbursement, and high-quality healthcare data reporting. The role involves reviewing medical records, collaborating with healthcare providers, supporting coding teams, and driving documentation quality improvements.

Key Responsibilities

• Review inpatient medical records for documentation accuracy, completeness, and consistency
• Perform concurrent chart reviews to validate severity of illness, risk of mortality, and complexity of care
• Collaborate with physicians, nurses, coders, and case management teams to improve documentation quality
• Support coding accuracy and compliance with ICD-10 Coding Guidelines and DRG reimbursement systems
• Analyze coding and documentation trends to identify opportunities for improvem...