Clinical Documentation Specialist - Full Time - Days

Job Summary

The Clinical Documentation Integrity (CDI) Specialist I serves as a vital liaison between healthcare providers, coding professionals, and quality teams. This role requires expertise in medical terminology, clinical procedures, and healthcare regulations to evaluate and validate medical documentation. The CDI Specialist I ensures documentation accurately reflects patient severity of illness and risk of mortality while maintaining compliance with regulatory guidelines and coding conventions.

Core Job Responsibilities

Provider Interaction and Clinical Documentation Review

• Develops and executes comprehensive queries (written and verbal) that include specific clinical context to enable complete provider responses.
• Ensures queries are non-leading and comply with industry standards.
• Implements Query Escalation Policy when provider responses are delayed or incomplete.
• Collaborates with CDI and coding teams during reconciliation to ensure accurate DRG, SOI, ROM, and POA assignments.
• Maintains ethical standards in all provider interactions and documentation practices.
• May participate in unit and patient rounds to promote accurate and complete documentation.

Concurrent Chart Reviews and Documentation Validation

• Performs systematic reviews of clinical documentation according to official coding guidelines.
• Assigns and validates ICD-10 principal and secondary diagnoses.  Validates ICD-10 PCS procedure codes.
• Identifies and clarifies missing, vague, or conflicting documentation that impacts DRG assignment, SOI, and ROM.  Validates findings and makes recommendations within CDI team before implementing next steps.  
• Ensures clinical validation of documented diagnoses.
• Reviews for clinical indicators.
• Validates that documentation supports reported diagnoses and procedures.

CDI Technology and Data Management

• Maintains comprehensive and accurate documentation in M*Modal CDI program and Epic EHR
• Utilizes CDI technology solutions effectively to streamline documentation processes

Quality Assurance and Compliance

• Adheres to all quality measures, regulations, standards and policies regarding documentation.
• Monitors and reports compliance concerns or unethical documentation practices
• Participates in quality improvement initiatives and corrective action plans
• Supports documentation capture of PSIs, HACs, and quality metrics and quality metrics
• Responsible for the accuracy and completeness of documentation reviews, query response rates and quality, impact on DRG accuracy and CC/MCC capture rates.

Interdepartmental Collaboration    

• Works closely with clinical staff, and coding professionals

• Perform related duties as required.
   

Education/Experience Requirements

REQUIRED:

• Associates degree in HIM, nursing or related field, or equivalent work experience.
• 2 years of experience in an inpatient coding, RN or documentation role. 
• Comprehensive understanding of medical terminology, patient care, and clinical procedures.
• Strong analytical and problem-solving abilities.
• Excellent interpersonal, written and verbal communication skills.
• Ability to collaborate effectively with diverse healthcare professionals.
   

PREFERRED:

• Bachelor’s degree in a related field.
• Expertise in ICD-10 coding guidelines as outlined through AHIMA and clinical documentation standards via ACDIS
• Proficiency in CDI/coding technology, including encoder software or electronic health record. 
   

Licensure/Certification Requirements

REQUIRED:

• RHIA or RHIT certification or RN license.

PREFERRED:

• CCDS/CDIP/CCS.

Disclaimer

Qualified applicants will receive consideration for employment without regard to their age, race, religion, national origin, ethnicity, age, gender (including pregnancy, childbirth, et al), sexual orientation, gender identity or expression, protected veteran status, or disability.

Successful candidates might be required to undergo a background verification with an external vendor.

Job Details

Req Id  94339 
Department  CLINICAL DOCUMENTATION IMPROVE 
Shift Days
Shift Hours Worked  8.00
FTE 1 
Work Schedule  SALARIED GENERAL
Employee Status A1 - Full-Time 
Union Non-Union
Pay Range $67k - $86k/Annually