Job Description

1. CLINICAL DOCUMENTATION REVIEW

• Conduct concurrent and/or retrospective medical record reviews to assess documentation accuracy, completeness, and specificity.
• Identify documentation opportunities to clarify diagnoses, procedures, complications, comorbidities, and clinical indicators.
• Ensure documentation supports medical necessity and accurate MS-DRG/APR-DRG assignment.
• Serve as a technical expert in health record content and documentation requirements within the EHR.

2. PROVIDER COLLABORATION & QUERY PROCESS

• Initiate compliant, non-leading queries to physicians and providers to obtain clarification of diagnoses and procedures.
• Collaborate with coders to ensure discharge diagnoses accurately capture clinical status and care delivered.
• Educate providers on documentation best practices, coding guidelines, and regulatory requirements.
• Foster positive working relationships with medical staff to support documentation improvement initiatives.

3. REGULATORY COMPLIANCE & QUALITY

• Ensure documentation complies with CMS, AHIMA, ACDIS, and other regulatory standards.
• Monitor and support quality metrics, including case mix index (CMI), hospital-acquired conditions (HACs), PSI indicators, and value-based purchasing measures.
• Maintain audit-ready documentation practices.
• Develop and update documentation policies in alignment with CIHQ accreditation standards.

4. DATA ANALYSIS & REPORTING

• Track and report key CDI metrics such as query response rate, agreement rate, CMI trends, and financial impact.
• Participate in internal audits and performance improvement initiatives.
• Identify trends and recommend workflow or educational improvements.

• Provide ongoing education to providers and staff regarding documentation guidelines and regulatory updates.
• Support denial management by providing clinical justifications for appealed claims.
• Perform other duties as assigned.

• Associate or bachelor’s degree in nursing, Health Information Management, or related healthcare field required.
• RN, RHIA, RHIT, CCS, CCDS, CDIP, or other relevant certification preferred (or required within a specified timeframe).
• Minimum 3 years clinical experience in acute care; ER, ICU, med-surg, or case management preferred.
• Minimum 2 years CDI experience with concurrent record review and physician querying.
• Current unencumbered RN license in the state of practice (if nursing background).
• CCDS (ACDIS) or CDIP (AHIMA) certification preferred.
• Additional coding credentials (CCS, CPC, CIC) a plus.

• Prolonged sitting at a desk and working on a computer for medical record review.
• Adequate vision, hearing, and repetitive hand/wrist motions required.
• Ability to move about the facility for physician rounding and training sessions.

• Well lighted, heated and/or air-conditioned indoor clinical/office setting with adequate ventilation.
• On-site
• Travel to ECH hospital locations may be required.