CDI Specialist

Scope of Position:

The Clinical Documentation Specialist is responsible for supporting the hospital’s Clinical Documentation Review Program, which includes:

• Conducting medical record reviews
• Communicating with and guiding clinical staff to ensure compliance with documentation standards
• Monitoring regulatory and accreditation compliance
• Providing staff education and training

This position is also responsible for educating providers on identifying disease processes that reflect severity of illness (SOI), complexity, and acuity to ensure accurate coding and documentation. The specialist must demonstrate an understanding of complications, comorbidities, SOI, ROM (risk of mortality), case mix, and the impact of procedures on the billed record—and effectively impart this knowledge to providers and other members of the healthcare team.

Responsibilities

• Facilitate modifications to clinical documentation to support appropriate reimbursement for services rendered.
• Ensure that documentation accurately reflects patient care, is complete, and complies with CMS regulations.
• Collaborate with providers, case managers, coders, and other healthcare team members to maintain comprehensive and accurate health record documentation.
• Assist in identifying and classifying complication codes (PSIs/HACs) and medical necessity concerns.
• Communicate with physicians regarding documentation opportunities and requirements.
• Identify trends, variances, and opportunities for process improvement in documentation review.
• Ensure completeness and accuracy of clinical information used for core measures by prompting physicians as needed.
• Educate clinicians on documentation, coding, and reimbursement issues, as well as performance improvement methodologies.
• Conduct follow-up reviews to verify that clarification requests have been documented appropriately.
• Comply with HIPAA and organizational code of conduct policies.
• Review clinical issues with coding staff to assign accurate working DRGs.
• Serve as a member of the DRG Work Group.
• Collaborate with the electronic health record (EHR) development team to support CDI (Clinical Documentation Improvement) efforts.
• Participate in hospital committees and task forces, including denials management.
• Conduct research to maintain up-to-date knowledge on clinical topics, coding regulations, and healthcare economics.
• Contribute to a positive and collaborative work environment.
• Perform other duties as assigned to support departmental and organizational goals.

Qualifications

Required:

• Current Connecticut RN license, Medical Graduate, or Physician Assistant (PA)
• Minimum of 3–5 years of clinical experience or equivalent healthcare experience
• Strong knowledge of care delivery processes and medical record documentation tools
• Ability to work independently in a time-sensitive environment
• Excellent verbal and written communication skills

Preferred:

• Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP)
• Minimum of 1 year of experience in Clinical Documentation Improvement
• Working knowledge of one or more of the following areas:
  • Medical/Surgical Nursing
  • Critical Care
  • Care and Case Management
  • Surgical Services
  • Accreditation and Regulatory Compliance
  • Core Measures and Public Reporting of Hospital Quality Data
• Familiarity with Medicare coding/reimbursement regulations