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
Editorial Process and Content Quality
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