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Major Hospital

Inpatient/CDI Specialist

Pay: Not specified

Posted: 1 week ago

Location: Shelbyville, IN (Onsite)

Last Updated: 5 days ago

Hours: Full-Time

Expires: 10/2/2026

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What they do

A Clinical Documentation Specialist works with information technology systems and applications in health care organizations. Assists clinicians and staff with technology and implementing new systems. Creates systems for organizing and interpreting data and information for clinical trials. Records and manages clinical information about patients, including health assessments and diagnoses, test results, treatments, and follow up care requirements. Reviews and maintains patient records.

$76,608 / year median in Indiana

-2% projected decline

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Job Description

JOB SUMMARY AND SPECIFICATIONS JOB SUMMARY

The Clinical Documentation Specialist reviews and analyzes medical records to identify relevant diagnoses and procedures for distinct patient encounters. This position is challenged to be aware of the continual changes in Federal and State regulations for prospective payment, keep informed of changes in clinical treatment modes and new procedures, and to perform queries when Physician documentation is vague or missing. The Clinical Documentation Specialist also performs Utilization Management duties including: evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedure and facilities under the provisions of the applicable health benefits plan.

MINIMUM QUALIFICATIONS

Professional & Technical Skills Strong computer skills. Effective communication skills, both written and verbal; three years or greater of medical coding experience; experience with 3M CDIS software preferred. Education Bachelors Degree or above, preferred License(s) or Certification(s) Certified Coding Specialist (CCS), Certified Professional Coder (CPC), or Certified Inpatient Coder (CIC) certification. ICD10 prepared. Clinical Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) certification preferred. LPN or RRT or

RHIA/RHIT

preferred. Other Skills or Requirements Ability to work independently. Exceptional customer service and critical thinking skills. Skilled to Care for Certain Age-Related Patient Groups (incumbents will be skilled in the care of the following patient groups) _____ Does not apply _____ Adolescence (13-17 years) __X__All age groups _____ Infants (0-1 year) _____ Geriatric (65+ years) _____ Pediatric/Early Childhood (1-12 years) _____ Adult (18-64 years)