Job Description
Job Overview: Day-to-day our Clinical Documentation Improvement Specialists are primarily responsible for evaluating concurrent documentation so that the medical record appropriately reflects the severity and risk of the patient’s conditions. Under the supervision of the CDI Leadership, CDI Specialists will conduct review of medical records to identify missing, vague and or incomplete diagnosis; c
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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