Clinical Documentation Spec

## clinical documentation spec

• Demonstrates understanding of appropriate clinical documentation to ensure severity of illness, risk of mortality, quality indicators, and resource utilization are accurately reflected.

• Communicates with and educates physicians and healthcare team members regarding documentation.

• Conducts concurrent and retrospective reviews of selected patient health records.

• Formulates compliant documentation clarification queries.

• Interacts with physicians, nurses and ancillary staff.

• Demonstrates an understanding of ICD-10 CM and PCS coding concepts and complex clinical scenarios.

• Codes relevant working diagnoses and DRG.

• Collaborates with coding staff.

• Demonstrates expertise in problem-solving.

• Leverages software tools for CDI data.

• Meets productivity and quality metrics as expected.

• Performs other duties as assigned by leadership.

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Qualifications

5+ years of Clinical experience

2+ Years of experience in clinical care, medical or surgical inpatient care nursing

Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN or LPN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate

Hospital coding experience/progressive experience in various hospital functions, including coding, reimbursement, finance, billing and/or various service areas

Prior CDI or Case management experience

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Education

AS Nursing

BS Nursing

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Certification

Registered Health Information Technician (RHIT)

Registered Health Information Administrator (RHIA)

CCDS

Registered Nurse Board Certified: Georgia Board of Nursing

Core Competencies

These competencies reflect the values and behaviors expected of all Grady team members, regardless of role. They ensure that every employee contributes to safe, high-quality care, positive patient experience, and a collaborative work environment.

• Patient-Centered Care – Demonstrates a commitment to delivering safe, compassionate, and high-quality care that prioritizes the well-being and satisfaction of patients and their families.

• Integrity & Accountability – Acts ethically, maintains confidentiality, and accepts responsibility for actions, decisions, and outcomes.

• Collaboration & Teamwork – Builds positive relationships, works effectively across departments, and supports colleagues to achieve shared goals.

• Communication – Communicates clearly, respectfully, and effectively with patients, families, colleagues, and leadership.

• Respect & Inclusion – Creates an inclusive environment by valuing diversity, treating others with dignity, and ensuring equitable care and opportunities for all.

• Quality & Safety – Adheres to best practices, regulatory standards, and policies to ensure safe, reliable, and high-quality outcomes.

• Adaptability & Resilience – Responds effectively to change, remains flexible in dynamic situations, and demonstrates resilience under pressure.

• Continuous Improvement – Seeks opportunities to improve processes, skills, and outcomes through innovation, learning, and feedback.

• Leadership & Professionalism – Inspires, guides, and develops individuals and teams while modeling professionalism, fairness, and transparency.

• Employee Experience Focus – Champions a supportive and engaging employee journey that enables staff to thrive and, in turn, deliver exceptional patient care.

Grady Total Rewards

At Grady, we believe in supporting the health, well-being, and growth of every team member. Our Total Rewards package is designed to provide competitive pay and comprehensive benefits that make a difference in your life and career, including:

Health & Wellness: Medical, dental, vision, and prescription drug coverage.

Financial Security: Retirement savings plans with employer contributions, life insurance, and disability coverage.

Work-Life Balance: Paid time off, holidays, and family leave benefits.

Career Growth: Tuition reimbursement, professional development programs, and opportunities for advancement.

Employee Support: Employee Assistance Program (EAP), wellness initiatives, and discounts on services.

Grady’s Total Rewards are designed to ensure our employees feel valued, supported, and empowered, both at work and beyond.

Why Join Grady?

Grady Health System is more than a hospital — we are a vital part of Atlanta and the surrounding communities. For over 125 years, Grady has been committed to providing exceptional care, advancing health equity, and making a difference in the lives of those we serve. When you join Grady, you become part of a team that values excellence, compassion, innovation, and collaboration.

Here, every role matters. Whether you provide direct patient care, support our operations, or lead teams, you play an important part in fulfilling our mission. We offer opportunities to learn, grow, and build a meaningful career in an environment where your contributions are recognized and valued.

At Grady, we don’t just work, we make an impact.