• Interpret complex clinical study protocols and other medical/scientific documentation • Prepare and coordinate laboratory specification and study-specific medical/technical documents • Partner with internal departments in document development, drafting, review, editing, and finalization • Manage multiple rounds of internal and external document review • Serve as a subject-matter expert (SME) for medical documentation • Participate in client interactions during study start-up activities • Maintain knowledge of FDA, MHRA, NYSDOH regulations • Resolve challenges and build consensus among cross-functional groups and collaborators

• Initiates and performs concurrent documentation review of selected inpatient records to clarify conditions/diagnosis and procedures where inadequate or conflicting documentation is suspected. Meets or exceeds defined performance standards for chart reviews and queries. • Improves coding specificity by educating physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay. This includes capturing complications/co-morbidities during the patient’s stay. This is achieved via queries, face-to-face communications, and/or other educational programs and tools useful and necessary to achieve this goal. Serves as a resource for physicians to help link ICD-10-CM coding guidelines and medical terminology to improve accuracy of final code assignment. • Follows guidelines for coding and documentation to ensure physician and hospital compliance. Remains current with coding information to ensure accuracy of codes assigned based on documentation. Participates in educational programs and in-services in order to maintain and exceed excellence in coding skills. • Performs ongoing CDI Final Review/DRG Reconciliation and reports DRG mismatch disagreements for secondary review as defined. • Other related job tasks or responsibilities as assigned

• Utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. • Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review. • Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. • Participates in the development and delivery of education for providers and members of the healthcare team.

• Implements and continuously develops onboarding for all new Clinical Documentation Specialists (CDSs) for mentoring and education needs. • Leads and coordinates training of new CDI staff. • Collaborate with CDI leadership and other clinicians to facilitate the ongoing relevance of department specific orientation content, educational materials, and training programs/resources. • Formulates customized education to other healthcare professionals based on audience and areas of opportunity. • Interacts with medical staff members, directors, and senior hospital leadership staff as needed. • Makes recommendations for documentation improvement and queries to capture care and intensity of services as supported within the medical record documentation. • Demonstrates understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix index, secondary diagnoses, and the impact of procedures on the final Diagnosis Related Group (DRG). • Educate members of the CDI team and providers on the review functions within the CDI program to meet and maintain enterprise goals and objectives, regulatory compliance, policies and procedures and standard operating procedures. • Assist with the development and maintenance of system CDI policies and procedures. • Remain current on CDI guidelines and practices. • Ensures program compliance by following coding guidelines and coding clinics. • Remains current with coding information to ensure accuracy of codes assigned based on documentation. • Serve as a key resource for accurate and ethical documentation standards and regulatory requirements. • Demonstrates the ability to draft compliant queries as endorsed by AHIMA and ACDIS. • Performs medical record reviews for completeness and accuracy in capturing severity of illness, risk of mortality and clinical validation. • Determines if professionally recognized standards of quality care are met. • Audits CDSs as needed to ensure that system objectives are met. • Develops educational plan for individual CDS based on Quality Audit (QA) outcomes. • Provides 1:1 mentoring as needed. • Oversees and coordinates SMART related education, meetings, and requirements for the department and as instructed by the SMART department.