Job Description
Description Job Summary : The Clinical Documentation and Performance Improvement Specialist is responsible for reviewing patient medical records to facilitate modifications to clinical documentation through concurrent (pre-bill) interaction with providers and other members of the healthcare team to promote accurate capture of clinical severity of illness and risk of mortality (later translated int
8:00 AM
Coders start the day by pulling their assigned chart queue. In a hospital setting, an inpatient coder might work 15–25 charts per…
8:30 AM
Open the first chart. Read the operative report, discharge summary, and physician notes. Assign the principal diagnosis code (the…
10:30 AM
Encounter a complex chart — a patient with multiple comorbidities and a surgical complication. You spend extra time to capture eve…
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