Non-Clinical - Clinical Documentation Specialist

Job Title: Clinical Documentation Specialist IIProfession: Non-Clinical Specialists/ProfessionalsSpecialty: Clinical Document ImprovementDuration: 13 weeksShift: DaysHours per Shift: 8 hoursExperience: Minimum 3 years of inpatient adult experience; critical care and trauma experience preferredLicense: Active clinical or health information credential requiredCertifications: CDIP or CCDS requiredMust-Have: Working knowledge of clinical documentation improvement (CDI) review and query practicesUnderstanding of documentation accuracy requirements, quality measures, and risk adjustment principlesExcellent verbal and written communication skillsStrong ability to apply clinical knowledge to documentation review and clarificationDescription: Independently conducts concurrent and/or retrospective reviews of inpatient medical records across assigned service lines. Identifies and acts on documentation gaps related to principal diagnosis, secondary diagnoses, complications, comorbidities, procedures, and clinical validation. Applies advanced clinical reasoning to assess consistency between clinical indicators and documented diagnoses. Prioritizes high impact cases based on acuity, quality indicators, and organizational focus. Independently formulates and issues compliant, non-leading CDI queries following established policies and nationally recognized query standards. Manages query follow up and escalation in alignment with established processes. Ensures queries are clinically sound, clearly written, and appropriately supported by documentation. Communicates effectively and professionally with providers to clarify documentation and promote best practices. Serves as a trusted documentation resource for providers within assigned service lines. Collaborates proactively with Coding, Quality, Case Management, and other interdisciplinary teams to resolve documentation and coding discrepancies. Identifies documentation opportunities impacting quality metrics and clinical validation. Adheres to regulatory and compliance requirements, including privacy standards. Serves as an informal mentor and resource to junior staff. Shares knowledge and best practices related to documentation standards and CDI workflows. Participates in ongoing CDI education and professional development activities. Performs other duties as assigned.