• Provides concurrent and subsequent reviews of the clinical documentation in the medical record using documentation improvement guidelines. Evaluates and identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure overall quality and completeness of the record. The key responsibility is to review the chart for information not currently in the chart but supported by clinical indicators; then queries the medical staff when necessary through written or verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality. • Performs a thorough chart review to determine the most appropriate principal diagnosis of the patient. • Performs a thorough chart review to identify co-morbidities/complications and documents these appropriately within the concurrent CDS worksheet. • Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses. • Coordinates with coding/HIM/UR and other departments to ensure the coded record reflects the acuity of patients and level of provider care. • Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization. • Maintains the ability to be flexible and prioritizes daily responsibilities. • Uses strong and professional communication skills with providers to clarify information in the medical record. Uses appropriate and compliant querying tools (templates) to capture needed documentation. Conducts follow-up on unanswered queries during the patient stay to obtain a response to unanswered queries. • Provides education to physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or individually with physicians. • Reviews the progress of the CDI program by interpreting performance, process, and quality ratings reports. Identifies areas of focus through report analysis. • Experience with CDI for Peds, Neonatal, and OB.