CLINICAL DOCUMENTATION IMPROVEMENT SPECIALIST SKILLS, EXPERIENCE, AND JOB REQUIREMENTS

Published: July 15, 2024 - The Clinical Documentation Improvement Specialist with entry-level experience and coursework in medical terminology anatomy and physiology demonstrates strong analytical thinking and problem-solving skills. This role requires effective verbal and written communication abilities to allow for the effective presentation of ideas and concepts to physicians, management, and healthcare team members. Holding a CCDS or CDIP certification, the specialist is self-motivated, able to work independently, and excels in collaborative, creative, and challenging environments.

Essential Hard and Soft Skills for a Standout Clinical Documentation Improvement Specialist Resume
  • Medical Coding
  • Clinical Documentation
  • ICD-10 and CPT Coding
  • Health Information Systems
  • Quality Assurance
  • Data Analysis
  • Medical Terminology
  • Regulatory Compliance
  • Electronic Health Record Proficiency
  • Audit Procedures
  • Attention to Detail
  • Communication
  • Problem-Solving
  • Critical Thinking
  • Adaptability
  • Team Collaboration
  • Time Management
  • Organizational Skills
  • Ethical Judgement
  • Persistence

Summary of Clinical Documentation Improvement Specialist Knowledge and Qualifications on Resume

1. BS in Nursing with 3 years of Experience

  • Previous experience in case management and/or critical care
  • Current certification as a CCDS, CDIP, or CCS
  • Previous experience as a Clinical Documentation Integrity Specialist
  • Education in Nursing with a board-approved nursing program with a passing score on the National Council Licensure Exam (NCLEX) or State Board Test Pool Exam (SBTPE) with acute care experience
  • Current RN license in any state with acute care experience
  • Medical School Graduate with CDI experience
  • RHIT or RHIA with a CCS with inpatient coding experience
  • Experience communicating and working closely with Physicians
  • Basic proficiency using a PC in a Windows environment, including Microsoft Word, Excel, and Electronic Medical Records (Cerner)
  • Excellent verbal and written skills including strong organizational skills

2. BS in Clinical Documentation Improvement with 4 years of Experience

  • Recent acute care clinical experience with Med/Surg, ICU, MICU, or adult populations
  • Must have an active licensure to practice as a Registered Nurse
  • A physician with direct patient care experience as a licensed physician 
  • Excellent communication skills, both written and verbal, as well as good Interpersonal skills 
  • Strong written and oral communication skills, and computer literacy.
  • Familiar with DRGs and coding guidelines and how documentation impacts DRG assignments.
  • RHIA or RHIT with current credentialing status with AHIMA (American Health Information Management Association)
  • Basic proficiency using a PC in a Windows environment
  • Active CCDS (Certified Clinical Documentation Specialist) from ACDIS (Association of Clinical Documentation Integrity Specialists) or active CDIP (Certified Documentation Improvement Practitioner) from AHIMA

3. BS in Medical Informatics with 5 years of Experience

  • Have a Licensed Registered Nurse- BSN or RHIA degree Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP)
  • Proven working experience with acute care
  • Recent inpatient coding working experience in an acute care setting. 
  • Experience working with coding and/or clinical setting 
  • Knowledge of Epic, 3M encoder 
  • Working knowledge of ICD-10 CM and PCS Coding and Inpatient Prospective Payment System 
  • Excellent communication skills, both written and verbal, as well as good Interpersonal skills 
  • The ability to offer flexibility amongst all Ardent facilities 
  • Ability to converse with physicians in sometimes difficult training scenarios. 
  • The ability to conduct brief presentations to facility physicians and leadership. 

4. BS in Health Information Management with 6 years of Experience

  • Entry-level or minimal experience in a Clinical Documentation Integrity Specialist (CDIS) role 
  • Must have completed coursework in medical terminology and anatomy and physiology).
  • Demonstrated skills in analytical thinking, and problem solving. 
  • Effective verbal and written communication
  • The ability to present ideas and concepts effectively to physicians, management and other members of the healthcare team. 
  • Self-motivated and able to work independently without close supervision. 
  • Demonstrated ability to work well with others in a creative and challenging work environment. 
  • Must have the Certified Clinical Documentation Specialist CCDS) or the Certified Documentation Improvement Practitioner (CDIP) certification
  • Have any of the following Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician-based (CCS-P), Registered Nurse (RN), completion of the international or domestic medical program or formal education (accredited college-level course work) in human anatomy and physiology, medical terminology, and disease process
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