CDI Specialist

Clinical Documentation Integrity Specialist

The Clinical Documentation Integrity Specialist (CDIS) reports to the VP of Clinical Documentation Integrity. The CDIS performs clinical documentation integrity (CDI) activities to support the accuracy, quality, and completeness of patient encounters at all inpatient NCH facilities. This role ensures that documentation practices maintain integrity to ensure coded diagnoses and procedures reflect the accuracy of the patient’s clinical status and care provided.

Essential duties and responsibilities include:

• Strategically facilitates and obtains appropriate and quality physician documentation for any clinical conditions or procedures to support the accuracy and integrity of the patient encounter and complexity of care.
• Educates members of the patient care team regarding documentation guidelines including physicians, allied health practitioners, nursing and care management as well as other ancillary staff as needed.
• Reviews concurrent medical records for documentation compliance including completeness and accuracy of each patient encounter for inpatient encounter types.
• Completes accurate and timely record review to ensure the integrity of documentation compliance.
• Recognizes opportunities for documentation improvement using strong critical thinking skills.
• Initiates/formulates CDI worksheets and clinically credible queries for inpatients, sending/presenting opportunities for improved documentation compliance to physicians, mid-level providers (including residents/fellows) following best practice guidelines aligned with AHIMA/ACDIS query practice brief.
• Proficient in formulating queries that are appropriate, compliant and effective.
• Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation.
• Communicates/collaborates with HIM staff (coding professionals) to resolve discrepancies with MS-DRG assignment and other coding/documentation issues.
• Completes well timed follow up case reviews on all cases with priority to aid in bridging the gap between clinical and coding terms.
• Completes accurate and concise input of data into CDI software resulting in accurate metrics to meet program KPIs.
• Participate in department and system wide meetings.
• Assumes personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency.
• Spends most of the work weeks on-site at the hospital as a resource, developing relationships, providing education, participating in hospital initiatives/committees.

Education, experience and qualifications:

• Minimum of Associates Degree required, Bachelor's Degree preferred.
• Minimum 3 years of acute care hospital nursing experience required, ICU preferred.
• Minimum 3 years CDI experience with CDIP or CCDS/CCS Certification preferred.
• Licensed as a Registered Nurse (RN) in the State of Florida.
• Strong knowledge of CDI principles, inpatient coding guidelines, and quality metrics.
• Excellent analytical and problem-solving skills to identify opportunities for documentation integrity.
• Effective communication and interpersonal skills to collaborate with physicians and interdisciplinary teams.
• Ability to develop and deliver educational programs tailored to clinical and administrative audiences.
• Strong organizational skills and attention to detail to manage multiple priorities and deadlines.
• Commitment to maintaining compliance with regulatory standards and corporate policies.
• Proficiency in computer use, including database and spreadsheet analysis, presentation programs, word processing, EMR(EPIC) and CDI technology.
• Onsite/Hybrid depending on department needs.