Clinical Documentation Improvement Specialist

Job Description

Job Description

Job Title: Clinical Documentation Improvement Specialist
Location: White Plains, New York
Schedule: Full-Time | Day Shift | Monday–Friday, 8:00 AM–4:00 PM
Pay Range: $95,373–$143,059 annually
Hours Per Pay Period: 75

Job Overview

A healthcare organization in White Plains, New York, is seeking an experienced Clinical Documentation Improvement Specialist (CDIS) to support accurate, complete, and clinically appropriate documentation across the medical record.

The CDIS will perform concurrent and post-discharge chart reviews, identify documentation opportunities, and collaborate closely with physicians, advanced practice providers, coding professionals, case management, and nursing staff.

This role requires a strong adult acute-care clinical background, advanced knowledge of disease processes and pathophysiology, and a solid understanding of coding guidelines, DRG assignment, severity of illness, risk of mortality, and quality measures.

Responsibilities

• Review inpatient medical records for completeness, accuracy, severity of illness, and quality
• Perform timely initial and concurrent clinical documentation reviews
• Identify opportunities to improve documentation and accurately reflect the patient's clinical condition
• Ensure documentation supports appropriate diagnosis coding and the level of care provided
• Develop clinically credible physician queries and documentation clarification requests
• Query providers regarding:
• Principal diagnosis
• Comorbidities and complications
• Severity of illness
• Risk of mortality
• Risk adjustment
• Quality measures
• Follow up on outstanding documentation queries and ensure timely resolution
• Collaborate with physicians, nurse practitioners, physician assistants, case managers, coders, nurses, and other care-team members
• Partner with Health Information Management and coding teams to resolve documentation and coding discrepancies
• Support accurate and appropriate DRG assignment
• Perform post-discharge reviews and query reconciliation
• Correlate clinical findings, abnormal laboratory results, medications, and treatment plans with documented disease processes
• Apply current inpatient coding and documentation guidelines during medical-record review
• Educate clinical staff regarding documentation improvement opportunities and CDI program processes
• Participate in CDI team meetings and education initiatives
• Maintain accurate documentation of CDI activity within the electronic medical record and CDI software
• Perform other related responsibilities as assigned

Qualifications

Required

• BSN or Bachelor's degree
• Approximately 5 years of adult acute-care clinical experience in one or more of the following:
• Medical-Surgical
• Critical Care / ICU
• Emergency Department
• PACU
• Minimum score of 70% on the Clinical Competency Assessment (CCA)
• Strong knowledge of pathophysiology and disease processes
• Strong understanding of anatomy, physiology, and pharmacology
• Ability to correlate abnormal laboratory findings and clinical indicators with disease processes
• Knowledge of official coding guidelines and documentation requirements related to the Inpatient Prospective Payment System
• Understanding of DRG assignment and clinical documentation requirements
• Knowledge of coding guidelines and healthcare quality measures
• Knowledge of the healthcare regulatory environment
• Ability to understand and communicate differences between Medicare Part A and Part B guidelines and their impact on DRG assignment
• Strong critical-thinking, analytical, problem-solving, and deductive-reasoning skills
• Excellent written, verbal, organizational, and interpersonal communication skills
• Basic computer proficiency and familiarity with Windows-based software

Licensure

Candidates must meet one of the following, when applicable to their professional background:

• Registered Nurse: Current New York State RN license upon hire
• Physician Assistant: Current New York State PA license upon hire

Preferred Background

• Previous Clinical Documentation Improvement experience
• Experience working with inpatient coding or Health Information Management teams
• Familiarity with CDI software and electronic medical records
• Knowledge of severity of illness and risk-of-mortality methodologies
• Experience with physician education and clinical documentation queries
• Strong understanding of Medicare reimbursement and inpatient quality measures

Benefits

• Competitive salary based on experience and qualifications
• Comprehensive health and wellness benefits
• Retirement plan
• Paid time off
• Professional-development and continuing-education opportunities
• Career growth within clinical documentation, quality, coding, and healthcare operations

If you are an experienced acute-care clinician with strong clinical judgment and an interest in documentation accuracy, coding integrity, and healthcare quality, we would love to hear from you.