Job Duties
Clinical documentation improvement specialists perform concurrent reviews of patient health records to ensure complete, accurate, and specific clinical documentation. They have a comprehensive understanding of CMS Coding Guidelines and are responsible for clarifying conflicting, incomplete, or imprecise documentation by actively seeking answers and educating active providers.
Their daily routines probably include the following responsibilities:
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Reviewing overall quality and completeness of clinical documentation.
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Reviewing patient records with an emphasis on improving documentation.
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Applying comprehensive knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures to ensure proper code selection.
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Adhering to accepted coding practices, guidelines, and conventions.
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Assisting facility staff with documentation requirements to completely and accurately reflect the patient care provided.
Work Environment
Inpatient clinical documentation improvement specialists are often onsite as they complete concurrent reviews. This allows them to have real-time dialog with the provider as they review patient charts and records. Remote work is becoming more common for this role, however that would depend upon the individual needs of the organization.
Pay Scale
As this career path is a level above standard medical coding roles, the salary potential is pretty significant. The average salary for professionals in this career is $77,737.
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*PayScale. “Average Clinical Documentation Specialist Yearly Pay” Payscale.com. Accessed May 2, 2023.
Statements found on PayScale are not a guarantee of any post-graduation salary, in part because the data used to estimate salaries includes workers from differing educational backgrounds, levels of experience, and geographic areas of the country.