Clinical Documentation Specialist

Job Description

The Clinical Documentation Improvement Specialist will work with physicians to facilitate appropriate clinical documentation to ensure that the level of services and acuity of care are accurately reflected in the medical record. Conducts follow-up reviews to ensure that clinical documentation clarified with the physician has been recorded in the medical record, and has been coded by the hospital HIM Coding staff.


  • Conducts concurrent review of inpatient medical records on assigned units to ensure that the acuity of care and specificity of diagnoses are accurately reflected in the medical record.
  • Completes Documentation Clarification communication tool when physician needs to be queried around clinical documentation issues.
  • Conducts follow-up review to ensure physician review and response to these clarification requests.
  • Works with department Director and hospital Medical Directors to escalate identified medical staff documentation issues, trends and medical staff compliance issues as needed.
  • Acts as adhoc coverage for CDI staff at other UC Health hospitals, as needed.
  • Provides ongoing educational updates to physicians on documentation and revenue cycle rules and regulations.
  • Enters information into appropriate databases as required to be used for statistical and performance improvement reporting purposes.
  • Works with hospital HIM Coding staff to ensure documentation clarifications have been reviewed and coded appropriately as part of the revenue cycle process.
  • Assists with the orientation, coaching and mentoring of new CDI associates, as needed.
  • Stays abreast of clinical documentation improvement resources to facilitate process efficiencies and educational needs.


  • Registered Nurse from an accredited school of Nursing, College or University required.
  • Bachelor of Science in Nursing (BSN) preferred, but not required.
  • Current RN License in Ohio
  • At least two years CDI experience preferred. Will accept at least three years acute inpatient med/surg experience, case management/UR experience, or clinical auditor experience.