Clinical Documentation Integrity Specialist - FT40

Job Description 

Job Title: Clinical Documentation Integrity (CDI) Specialist           Department: Quality Management 

Reports to: Quality Coordinator                                                         FLSA Status: Non-Exempt (Hourly)

Job Summary:

The Clinical Documentation Integrity Specialist at Wooster Community Hospital plays a critical role in ensuring the quality, accuracy, and completeness of clinical documentation within the healthcare setting. This position focuses on reviewing patient records to identify gaps or inconsistencies in documentation, collaborating with healthcare providers to clarify and improve clinical notes, and supporting compliance with regulatory standards and coding requirements. The specialist contributes to enhancing patient care outcomes by facilitating clear communication among multidisciplinary teams and ensuring that documentation accurately reflects the patient's clinical status and treatment. Additionally, this role supports hospital initiatives related to quality improvement, reimbursement optimization, and data integrity. Ultimately, the CDI Specialist helps maintain the hospital’s commitment to delivering high-quality healthcare services through precise and thorough clinical documentation.

Duties/Responsibilities:

Clinical Documentation Review:

•  Review and analyze clinical documentation in patient medical records to ensure accurate, complete, and clinically supported documentation.
• Identify clinical indicators and gaps requiring clarification or enhancement to reflect the true patient condition. 
• Utilize evidence-based criteria to validate diagnoses, procedures, and clinical treatment plans.

Query Management

• Identify appropriate need for provider queries.
• Compose clear, compliant provider queries to obtain additional clinical information or clarification.
• Collaborate with providers to ensure timely, accurate responses.
• Track, trend, and report query outcomes and provider engagement.

Collaboration & Communication

• Collaborate with providers, nurses, and other healthcare professionals to clarify documentation and obtain additional information as needed.
• Partner with providers, coders, case managers, and quality teams to ensure alignment on CDI program needs. 
• Collaborate proactively with WCH physician advisors. 
• Develops multidisciplinary collaborative relationships using interpersonal skills to build and maintain crucial relationships. 

Data Integrity & Compliance 

• Monitor compliance with documentation standards and support coding and billing teams to optimize reimbursement.
• Maintain up-to-date knowledge of healthcare regulations, coding guidelines, and documentation standards.
• Ensure all CDI practices follow compliant query guidelines and organizational policies.
• Educate providers and clinical staff on documentation best practices and regulatory requirements to improve overall documentation quality.

Performance Improvement

• Participate in quality assurance activities and provide feedback and education to clinical teams to enhance patient care documentation.
• Assist in the development and implementation of documentation improvement initiatives, audits, and policies.
• Analyze documentation trends and opportunities for ongoing program enhancement. 
• Support organizational initiatives related to quality metrics, value-based programs, and risk adjustment. 

Required Skills/Abilities: 

• Excellent verbal and written communication skills. 
• Excellent interpersonal and customer service skills.
• Excellent organizational skills and attention to detail.
• Excellent time management skills with a proven ability to meet deadlines and work independently.
• Strong analytical, problem-solving skills with the ability to identify opportunities for improvement.
• Strong understanding of pathophysiology, pharmacology, and medical terminology.
• Ability to demonstrate appropriate assertiveness with a positive solution focused attitude. 
• Ability to manage multiple priorities.
• Ability to function well in a high-paced and at times stressful environment.
• Proficient with electronic health record systems.
• Proficient with Microsoft Office Suite or related software.

Education and Experience:

Required:

• Bachelor’s degree in nursing with active RN license 
• 2 years’ experience in an acute care facility in coding, case management, nursing, quality review, and/or other related area.
• Prior CDI experience 
• CDI certification within 12-24 months of hire. 

Preferred:

CDI certification at the time of hire

Coding certification at the time of hire

Effective Date: 12/1/2025

Revision Date(s): 12/1/2025