Job Overview. A clinical documentation specialist reviews a patient's medical records to ensure documentation is accurate and up-to-date with the latest information on a patient's illness. They also record the details of every step in clinical treatment. A CDS must have familiarity with codes involved with medical records, each of which is used to indicate some aspect of the patient's medical information, condition, and treatment received. Key Re...
The CDI Specialist will be assisting with documentation improvement activities for accurate ICD-10-CM code assignment. This individual will play a key role in adherence to official coding guidelines, corporate compliance policies, and appropriate reimbursement for the hospital. At least one of the following is required: RHIA or RHIT
