Job Description

Our client is looking for a Clinical Documentation Analyst who will be responsible for performing detailed reviews of patient records to ensure medical documentation is clear, accurate, and supports the full scope of patient care provided. This role requires collaboration with various departments—including coding, quality assurance, case management, and medical staff—to ensure the patient’s health status and treatment complexity are fully captured for reporting and reimbursement purposes.

Primary Responsibilities:

• Conduct real-time reviews of inpatient charts to verify the completeness and accuracy of physician documentation prior to discharge.
• Evaluate newly admitted cases daily and assign preliminary diagnosis-related groups (DRGs), logging all relevant data into the clinical review platform.
• Adjust provisional DRGs when additional documentation or physician clarification warrants changes.
• Notify team leadership when daily assignment volumes require redistribution.
• Draft provider queries when information is unclear, incomplete, or lacks specificity, and follow up for timely responses.
• Use evidence-based practices and industry guidelines to ensure all documentation meets compliance standards and accurately reflects patient acuity.
• Collaborate with coding and compliance teams to support audit readiness and accuracy in reporting.

Required Qualifications:

• Bachelor's degree in a healthcare-related discipline
• Active RN license, MD, or equivalent international medical degree (e.g., MBBS)
• 2–4 years of experience working in clinical documentation review or hospital coding within an acute care setting
• Knowledge of DRG structures, clinical coding platforms, and standard classification systems
• Up-to-date on medical coding rules and official coding guidelines

Preferred Qualifications:

• Certifications such as CCDS or CDIP are a plus
• Solid understanding of clinical conditions, disease processes, and medical procedures
• Demonstrated critical thinking, problem-solving skills, and attention to detail
• Proficient in using electronic medical record systems, documentation review software, and coding tools
• Comfortable engaging in conversations with healthcare providers to clarify medical record content
• Strong computer and typing skills

Compensation:

• Annual Salary Range: $74,000 – $124,000
• Actual compensation is based on experience, credentials, and other role-specific considerations

Please note: This job posting is just a preview of the full scope of the position. A comprehensive job description is shared by a member of our team.

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