Clinical Documentation Improvement Specialist (CDIS )

Job Description

Clinical documentation specialists assess medical records and documents for compliance with national-international regulations. Their duties include analysing medical information to assist healthcare providers, ensuring the accuracy of clinical documentation, and training staff on medical record procedures.

Clinical Documentation Specialist Responsibilities

• Applying knowledge of medical terminology and procedures to evaluate clinical documents.
• Verifying the accuracy of patient medical information and obtaining missing information.
• Monitoring diagnoses, treatments, and follow-up entries in medical records.
• Interpreting and preparing clinical reports for healthcare professionals.
• Meeting with healthcare stakeholders to explain findings and facilitate actions.
• Training medical and administrative staff in standard medical procedures.

Requirements

• Bachelor’s degree in Health Information Technology.
• Registered Health Information Technician (RHIT) preferred.
• Registered Nurse (RN) will be advantageous.
• Proficiency in Electronic Medical Record (EMR) software.
• A minimum of three years’ experience in a similar role.
• Advanced knowledge of best practices in medical record.
• In-depth knowledge of medical terminology, coding, and procedures.
• Extensive experience in collecting and interpreting medical information, as well as training staff.
• Ability to keep informed of advancements and regulations in clinical documentation.
• Excellent organizational and communication skills.