Job Description

Location: St. Joseph Medical Center
Posted Date: 10/24/2021

JOB SUMMARY: The Clinical Documentation Specialist is responsible for improving overall quality and completeness of clinical documentation in the health record ensuring compliance with the organization’s coding procedures and standards. The Clinical Documentation Specialist facilitates modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through interaction with physicians, care management, nursing staff, other patient caregivers and medical record coding staff while striving to eliminate gaps and assisting providers with accurate and compliant documentation resulting in appropriate healthcare reimbursement and clinical outcomes. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. Reports concurrent chart review and query outcomes to hospital departments and committees at designated intervals. Utilizes monitoring tools/software to track the progress of the CDI program. Maintains accurate records of review activities to comply with departmental and regulatory agency guidelines. Understands and complies with policies and procedures related to confidentiality of medical records. Identifies opportunities for intradepartmental and interdepartmental operational improvements. Participates in program related meetings, physician and staff education, staff development, departmental activities and in-service opportunities.


  1. Completes the initial review of a new admission patient health record within 24-48 hours of admission for a specified patient population to evaluate documentation and to assign a working principal diagnosis, pertinent secondary diagnoses, and procedures for a working DRG assignment, POA assignment, risk of mortality and severity of illness and initiates a working review worksheet.
  2. Re-reviews inpatient health records while patients are in-house, concurrently, for proper documentation. Follow-up re-review will be done every two to three days until the patient is discharged to assign a working or final DRG upon patient discharge.
  3. Initiates and completes queries regarding missing, unclear or conflicting documentation in the health record required for quality patient care and accurate DRG assignment concurrently.
  4. Interacts with ancillary departments to obtain missing information needed to properly support billing accounts based on documentation in the medical record.
  5. Attends daily case management meetings.
  6. Partners with HIM coding professionals to ensure accuracy of diagnosis and procedural data and completeness of supporting documentation to ensure documentation of discharge diagnoses and any


  1. Educates providers one-on-one in understanding the clinical documentation requirements for diagnosis capture both formal and informal. This includes nursing and other clinical staff regarding clinical documentation improvement and the need for accurate and completed documentation in the health record.
  2. Identifies clinical documentation issues and works with ancillary departments to resolve issues and notify appropriate leadership.
  3. Maintains clinical database updated and current. Produces reports as requested and produces monthly summary reports of cases reviewed. Reviews results for patterns, specific clinical issues and overall issues for noncompliance or possible educational needs.
  4. Performs concurrent record reviews on all selected admissions and documents findings.
  5. Serves as a team member and assists in recovery audit process reviews.
  6. Serves as a resource for physicians to help link ICD-10 CM coding guidelines and medical terminology to improve accuracy of documenting patient severity of illness, risk of mortality and final code assignment.
  7. Monitors and evaluates effectiveness of concurrent chart review and query outcomes at designated intervals.
  8. Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
  9. Adheres to all compliance guidelines and maintains strictest confidentiality.
  10. Supportive of the compliance program set forth by Steward and demonstrated by:
    1. Upholding the Standards of Conduct and Corporate Compliance.
    2. Adheres to and helps to enforce all compliance policies relevant to his/her area.
    3. Assures timely compliance education as requested by the Regional Compliance & Safety Officer and/or through corporate initiatives.
    4. Sets an example to all staff in their daily activities.
    5. Other duties as assigned.
    6. Consistently supports and communicates the Mission, Vision and Values of SJMC
    7. Follows the SJMC guidelines related to the Health Insurance Act of 1996 (HIPPA) designed to prevent and detect unauthorized disclosure of protected health information (PHI).
    8. Promotes a culture of safety for patients and employees through proper identification, proper reporting, documentation and prevention of medical errors in a non punitive environment.
    9. Maintains and uses proficiency in communication skills, both written and verbal.

      Strong broad-based clinical knowledge and understanding of pathophysiology of disease processes. Excellent written and verbal communication skills, critical thinking skills and interpersonal skills to build effective partnering relationships with physicians, care management team, nursing staff, coding staff and other hospital staff. Able to present ideas and concepts effectively to physicians, management and employees. Ability to work independently in a time oriented environment. Ability to analyze problems and issues from a variety of perspectives and understand the legal, reimbursement and impact.


      • Five years of experience in an acute care setting.
      • Knowledge of care delivery documentation systems and related medical record documents.
      • Prior experience in clinical documentation improvement programs preferred.


      • RN License, required
      • RNs with case management experience preferred
      • RNs with utilization review experience preferred
      • CDIP or CCDS required after 2 years of continuous employment


      • Bachelor of Science degree in nursing, preferred.


      • Excellent communication skills both verbal and written
      • Good interpersonal skills
      • Able to establish good customer relationships with trust and respect
      • Computer skills: navigation and edit resolution through various Web based systems; Proficient use of Microsoft office, specifically excel, Word, Outlook
      • Self directed, motivated and a positive attitude
      • Must exhibit excellent organizational skills
      • Clinical documentation knowledge as it relates to DRGs, POA, MCCs and CCs preferred
      • Understanding of the coding classification systems, ICD-10, CPT, HCPCS
      • Clinical knowledge to read and analyze a patient’s health record
      • Clinical understanding of pharmacology, pathophysiology, labs, radiology and disease processes

      For physical demands of position, including vision, hearing, repetitive motion and environment, see following description.

      Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising client care.

    Application Instructions

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