Documentation Specialist
Confidential
Seeking a full time ONSITE Clinical Documentation Integrity (CDI) Specialist 75 hours biweekly Located near Queens, NY Our healthcare client is seeking an experienced Clinical Documentation Integrity (CDI) to join its team. This role is ideal for a clinician with a strong clinical background and extensive CDI experience who is passionate about improving documentation quality, coding accuracy, and organizational performance. Responsibilities Review and audit inpatient medical records to ensure accurate, complete, and compliant clinical documentation. Partner with providers and coding teams to improve documentation supporting accurate ICD-10-CM/PCS, APR-DRG, and MS-DRG assignment. Educate physicians and clinical staff on CDI best practices and ICD-10 coding guidelines. Develop compliant provider queries following AHIMA standards. Write clinical appeal letters and support denial management initiatives. Analyze CDI metrics, identify improvement opportunities, and present findings to hospital leadership. Collaborate with coding, quality, compliance, clinical applications, and interdisciplinary teams to enhance documentation and reporting. Assist with EMR documentation optimization in systems such as Epic or MEDITECH. Lead CDI meetings, educational sessions, and provider training. Required Qualifications MBBS with ECFMG Certification 5 years of inpatient Clinical Documentation Integrity (CDI) experience. 3 years of clinical experience managing patients in an acute care setting. Expert knowledge of ICD-10-CM/PCS coding guidelines, clinical documentation, disease processes, and treatment protocols. Experience with DRG grouper software and electronic health records such as Epic or MEDITECH . Excellent communication, presentation, and relationship-building skills. Candidates must possess at least one of the following: ACDIS Certified Clinical Documentation Specialist (CCDS) AHIMA Certified Coding Specialist (CCS) If you're a clinically experienced CDI professional who enjoys collaborating with physicians, improving documentation quality, and driving organizational excellence, we'd love to hear from you. #J-18808-Ljbffr Confidential
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