Senior Hospital Clinical Documentation Improvement Specialist - FT - Day - Clinical Documentation Improvement Lawrenceville NJ

Clinical Documentation Improvement Specialist

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

$90,480.00 - $118,227.20

Scheduled Weekly Hours: 40

Position Overview

Responsible for optimizing the accuracy, completeness, and clinical integrity of provider documentation. Performs a second level review aimed at improving clinical documentation, coding accuracy and DRG optimization. Supports escalated documentation issues, mentors CDI team members, and collaborates with physicians, coding, and revenue cycle leadership to improve clinical documentation that impacts reimbursement, quality reporting, and patient outcomes. Responsible for assisting in developing, delivering, and leading education programs.

Minimum Requirements

Education: RN required, Graduate of an accredited school of nursing program. BSN, preferred. Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP), preferred

Experience: Three or more years' recent clinical experience in an acute care setting, preferable ICU or Medical/Surgical, or three or more years related coding experience or clinical documentation improvement specialist experience in a hospital setting in clinical documentation improvement in an acute care setting.

Other Credentials: Knowledge and Skills: Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues. Excellent verbal and written communication skills. Working knowledge of all areas of adult medicine. Knowledge of pathophysiology and disease process. Intermediate computer skills. Familiarity with windows-based software programs and encoding software

Special Training: Certification as CCDS or CDIP preferred.

Mental, Behavioral and Emotional Abilities: Ability to work in environment using multiple EMR systems. Excellent observation, analytical thinking, and problem-solving skills. Ability to learn/develop skills necessary to perform CDI. Flexible, dependable and self-directed. Ability to work independently. Demonstrates ethical conduct.

Usual Work Day: Reporting Relationships Does this position formally supervise employees? No

Essential Functions

Serves as key resource in CDI operational performance, quality initiatives, and organizational documentation improvement strategy

Performs advanced second-level reviews of medical records to optimize the accuracy, completeness, and clinical integrity of provider documentation and identify trends to identify gaps in documentation and training opportunities

Conducts in-depth reviews prior to final billing of target case populations, place queries if documentation opportunities are identified, and collaborate with the coding team on coding opportunities

Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed. Proactively identifies issues with reporting of diagnostic testing

Collaborates with CDI leadership to review trends related to DRG downgrades, query activity, and revenue cycle opportunities to inform educational content and strategic planning for CDI, HIM Coding, or Provider audiences.

Delivers targeted provider education on high-impact conditions, documentation pitfalls, and regulatory updates.

Participate in clinical quality committees and initiatives impacting documentation. Provides subject matter expertise to support organizational needs

Act as a mentor and resource to CDI Specialists, providing real-time feedback and training. Assist with onboarding, competency development, and ongoing education for new staff.

Collaborate with CDI leadership to refine workflows, policies, and documentation standards and interprets data trends. Leverage CDI software for case prioritization, query management, and analytics.

Periodically review the criteria established for cases triggering a second-level review and recommend updates or modifications to the criteria to assist in identifying areas of opportunity.

Meets or exceeds departmental accuracy and productivity standards. Fosters teamwork and collaboration. Assists in the appeal process resulting from third-party reviews.

Physical Demands and Work Environment

Frequent physical demands include: Sitting, Reaching forward, Wrist position deviation, Pinching/fine motor activities, Keyboard use/repetitive motion, Talk or Hear

Occasional physical demands include: Standing, Walking, Climbing (e.g., stairs or ladders), Carry objects, Push/Pull, Twisting, Bending, Reaching overhead, Squat/kneel/crawl

Continuous physical demands include:

Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 15 lbs.

Sensory Requirements include:Anticipated Occupational Exposure Risks Include the following: N/A

This position is eligible for the following benefits:

• Medical Plan
• Prescription drug coverage & In-House Employee Pharmacy
• Dental Plan
• Vision Plan
• Flexible Spending Account (FSA)
• Healthcare FSA
• Dependent Care FSA
• Retirement Savings and Investment Plan
• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance
• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance
• Disability Benefits Long Term Disability (LTD)
• Disability Benefits Short Term Disability (STD)
• Employee Assistance Program
• Commuter Transit
• Commuter Parking
• Supplemental Life Insurance
• Voluntary Life Spouse
• Voluntary Life Employee
• Voluntary Life Child
• Voluntary Legal Services
• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance
• Voluntary Identity Theft Insurance
• Voluntary Pet Insurance
• Paid Time-Off Program

The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level.

The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.