• Responsible for concurrent review of inpatient medical records to identify opportunities for improving quality of physician documentation • Facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the health care team • Achieves a complete medical record to support complete, accurate and timely coding • Communicates with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation • Utilizes the hospital’s designated clinical documentation system to identify opportunities for physician and hospital outcomes • Provides or coordinates education to internal customers related to compliance, coding, and clinical documentation issues • Responsible for the evaluation of documentation by the medical staff • Gathers and analyzes documentation findings and outcomes • Contributes to a positive working environment and performs other duties as assigned or directed

• The CDI Specialist is responsible for comprehensive secondary clinical chart reviews to identify potential missed opportunities for documentation clarification. • Collaborates closely with Coders, Coding Educators, Coding Quality Auditors, Case managers, Quality Department and Providers to assure documentation is clinically appropriate, accurately reflects the severity of illness and risk of mortality for the patient and is reflective of current CMS or other regulatory standards. • Conducts daily, concurrent review of inpatient records on assigned unit(s) to ensure complete and accurate physician and or clinician documentation is present at the time of discharge for accurate, timely, and compliant coding. • Reviews daily admissions to assigned unit, perform initial code assignment for a working DRG and complete CDI software data entry for initial and follows up case reviews (or worksheet to include code and DRG assignment) and submit to Program Assistant. • Updates “working DRG” as documentation supports, or physician query answer supports a change in the DRG assignment. • Communicates to the CDI Coordinator when volume of daily review assignments is too high or low so that CDI Coordinator can assist in adjusting review assignments amongst the team. • Initiates compliant physician queries when documentation is confusing, ambiguous, or missing and follows up with MD to seek immediate response to query.

• Develop high-quality medical and scientific content • Collaborate with internal stakeholders and external experts • Ensure content compliance with regulatory standards • Maintain up-to-date knowledge of therapeutic areas

• Develop high-quality medical and scientific content • Write clinical summaries and scientific manuscripts • Collaborate with medical affairs and regulatory teams • Ensure compliance with regulatory and ethical standards