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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical documentation integrity, coding standards, and regulatory compliance, with a strong focus on education and training for clinical staff. Proficient in auditing medical records and optimizing DRG assignments to enhance documentation quality.
Highest-signal resume keywords
Clinical Documentation IntegrityICD-10-CM/PCS CodingCoding Certifications (CCS, CCDS, RHIA, RHIT)Nursing License (RN) or EquivalentHealth Information Systems Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical DocumentationDRG AssignmentQuality Assurance ReviewsMedical Record AuditingRegulatory ComplianceDocumentation StandardsAnalytical SkillsEducation and Training DevelopmentRisk AssessmentDocumentation Quality Improvement
Soft Skills
CollaborationCommunicationInterpersonal SkillsPresentation SkillsTeam Collaboration
Tools & Technologies
Health Information SystemsExcelMedical Record Abstraction Tool
Certifications & Qualifications
ACDIS Certified Clinical Documentation Specialist (CCDS)Coding Certifications (CCS, CCDS, RHIA, RHIT)
Industry Keywords
Revenue Cycle ManagementInpatient Clinical DocumentationAcute Care SettingClinical EducationDocumentation Practices
About the role
Key responsibilities & impact- Act as liaison between CDI, coding, providers, and other teams to facilitate accurate clinical documentation
- Assist CDI manager with ongoing quality assurance reviews of clinical documentation staff, ad hoc, and special project reviews requiring advanced CDI and coding knowledge
- Audit medical records to ensure accurate DRG optimization, severity of illness, and overall documentation quality
- Orient and train new CDI staff as needed
- Develop and deliver CDI-related education and training for providers, coders, and staff
- Interpret and translate complex clinical information into coding/CDI concepts and recommendations
- Support compliance by ensuring documentation practices align with regulatory guidelines and MSK standards
- Assist in DRG denials/appeals process and formulate appeal letters
Requirements
What you’ll need- Experience in clinical documentation, coding, or revenue cycle management (inpatient and/or outpatient) preferred
- Current nursing (RN) license with bachelor’s degree in nursing or other related field, and/or graduate education leading to Physician Assistant (PA) with current PA license, and/or graduate education leading to MD, DO or equivalent degree
- Clinical experience in the acute care setting
- Coding certifications (CCS, CCDS, RHIA, RHIT) highly valued
- Experience with ICD-10-CM/PCS coding/ DRG assignment preferred
- Strong collaboration, communication, and education/training skills for working across clinical and non-clinical groups
- 2+ years experience in inpatient clinical documentation integrity and ICD-10-CM/PCS coding/ DRG assignment
- ACDIS Certified Clinical Documentation Specialist (CCDS)
- Master’s degree in nursing with advanced practice license and experience preferred
- Advanced knowledge of clinical documentation standards, coding requirements, and regulatory guidelines
- Analytical ability to identify trends, assess risks, and improve documentation quality
- Excellent interpersonal and presentation skills for provider education and team collaboration
- Proficiency with health information systems, Excel, and medical record abstraction tool
