Medical Records

Cookeville Regional Medical Center

Clinical Documentation Improvement Specialist Apply

This position is responsible for reviewing medical records to facilitate appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, improving the quality of the physicians’ clinical documentation,.  Exhibits a sufficient knowledge of clinical documentation requirements, MS-DRG Assignments and clinical conditions or procedures.  Educates members of the patient care team, regarding documentation guidelines, inclusion all physician and extenders.  Manages post-surgical documentation for accuracy of coding and documentation and appropriate status, which is directly related to reimbursement. Reviews dictated op notes Monday thru Friday for completeness, and contacts surgeons for needed documentation to support medical necessity.  Evaluates patient levels of care in conversation daily, and queries medical staff as needed to insure patients meeting inpatient status are converted appropriately. Manages and reconciles surgery schedule to insure precertification are present .Manages communication with outside physician advisor on a daily basis, and meets with attending physician when outside physician advisor recommends level of care changes, and insures that documentation and orders are completed. Ensures the timeliness of all written and verbal queries from providers to ensure proper documentations obtained and placed in the medical record before patient discharge. Maintains communication with physician office to provide education. Acts as a liaison to Transition of Care Committee for the Upper Cumberland Area to promote continuity for patients and reduce readmissions. Reports to Corporate Compliance and manages outliers.


  1. EDUCATION:  Tennessee Registered Nurse License, BSN preferred, or Registered Health Information Administrator with coding certification, CCS.


  1. EXPERIENCE:  Three to five years registered nurse clinical experience in similarly complex acute care setting. Familiarity with utilization review, case management, nurse review activities or coding experience preferred. RHIA candidate: Requires Certified Coding Specialist (CCS) certification; previous APR-DRG validation is required. Requires minimum three years previous validation experience and five plus years of coding and clinical documentation experience with extensive clinical knowledge in an acute hospital environment. RHIA will need to be familiar with InterQual criteria and match to documentation and coding guidelines. 

RN - Must be knowledgeable in: ICD-9-CM, (ICD-10-CM for 2014) APR-DRGs, DRGs knowledge or use of InterQual criteria and clinical guidelines for admitting patients to the hospital.

Both RHIA and RN - Requires excellent and comprehensive knowledge of anatomy, physiology, as defined by the Medical Diagnostic Categories and all body systems. Strong background knowledge of disease process and pharmacology. Requires a complete and thorough understanding of the unique functions of each clinical area. Previous experience working with the Executive Health Resources Physician Advisor Company preferred.

  1. SKILLS:  Knowledge of general office procedures, proficient computer skills in Microsoft Office required. Demonstrates a high level of communication with clinical and administrative staff. Ability to effectively communicate with all Hospital practitioners. Possesses excellent written, oral communication and interpersonal skills. Must be conversant in clinical documentation improvement.  High level of proficiency in adult education and training to develop and conduct ongoing CRMC CDI education for new staff, including new clinical documentation specialists, coders, physicians, residents, nursing and allied health professionals. Participates in ongoing education of staff. Develops educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians presented as handouts, PowerPoint, etc.

Must be self-sufficient, reliant and able to work well with others. Must be flexible and willing to accept and adapt to constant change due to changes enforced upon providers by Federal government/CMS local coverage determinations and national coverage determinations changes. 


Requires knowledge of clinical pertinence requirements and proficiency in abstraction and data entry into the entire data base systems used for clinical documentation. Must be able to read and interpret electronic and manual documentation generated by healthcare professionals.


Active CDIS certification or achievement expected within two years of employment.

ICD-10 Trainer & Auditor for Coding Quality Apply
1st, M-F

This position is responsible for providing supportive ICD-10 training and auditing.  Auditing the quality of coding is part of this position to ensure coding compliance and continued education.  This position also includes working with doctors/providers to improve problem areas which affect coding.  They may also complete special projects and/or provide backup coding during staffing shortages.


Associate’s or Bachelor’s level of education in related health field with credentials as Registered Health Information Administrator, Registered Health Information Technician, and/or Certified Coding Specialist, with proven experience as a qualified coder.   



Minimum of 3 years coding experience in an acute-care hospital with acceptable quality and productivity.   Understanding of other types of billing outside acute care, training and auditing experience are preferred.



Demonstrates extraverted communication style and confidence, especially in training, auditing, educating, and dealing with physicians and other clinical staff.  Demonstrates excellent understanding of, ICD-10 CM/PCS and CPT-4 coding functions, billing requirements and coding compliance.  Knowledge of general office procedures, proficient keyboard and computer skills, knowledge of general office equipment and procedures.  Must possess ability to work well under pressure, to function independently and dependently, and to be flexible in applying knowledge to a variety of situations. Must possess the ability to prioritize tasks, meet deadlines without being reminded and be flexible to changing needs of the Hospital and Department. Able to organize work to process in an efficient manner. Strong oral and written communication skills. Communicates well with others of all levels. Cooperative, congenial and positive behavior exhibited. .Must display tact and diplomacy in a variety of situations, with behavior and personal appearance reflecting a good image of Cookeville Regional Medical Center.



Constantly (activity exists 2/3 or more of time)



Requires good problem-solving skills, such as making difficult decisions regarding coding conflicts and billing issues. Ingenuity, judgment, compromise with other staff members and/or creativity may be needed in decision-making to satisfy customers, find the best solutions for all parties involved and/or to make improvements in hospital operations.