Clinical Documentation Improvement Specialist

Job Details
The Clinical Documentation Integrity (CDI) Specialist is responsible for conducting concurrent reviews of inpatient medical records to ensure accurate, complete, and compliant clinical documentation. This role focuses on identifying missing or understated diagnoses, facilitating physician queries, and collaborating with cross-functional teams to ensure the medical record reflects the true acuity of the patient and supports appropriate care, coding, and quality outcomes. The position requires strong clinical expertise, critical thinking, and effective communication with providers and internal stakeholders.
Job Responsibilities
Conduct initial and follow-up concurrent reviews of inpatient medical records to identify opportunities for improved documentation
Analyze clinical indicators to identify diagnoses or conditions not yet documented in the record
Determine and validate the appropriate principal and secondary diagnoses to accurately reflect patient acuity
Initiate and follow up on physician queries (written and verbal) to obtain complete and accurate documentation
Build and maintain strong working relationships with physicians to facilitate effective communication and documentation improvement
Provide education to physicians on documentation best practices, both in group settings and one-on-one
Document review findings and key information within workflow and tracking tools
Collaborate with Coding, HIM, and other departments to ensure alignment on documentation and level of care
Utilize data and feedback from leadership to prioritize focus areas and improve performance
Manage daily responsibilities effectively, maintaining flexibility in a fast-paced environment
Required Qualifications
Current RN, PA, or NP license in NYS
Minimum of 3 years of clinical experience in an acute care setting (e.g., inpatient bedside nursing, case management)
Strong clinical knowledge, including pathology and physiology
Excellent written and verbal communication skills
Strong critical thinking skills
Working knowledge of inpatient admission criteria
Ability to work independently and manage time effectively in a deadline-driven environment
Desired Attributes
Prior Clinical Documentation Integrity (CDI) experience (preferred but not required)
Ability to think proactively and identify gaps in documentation
Strong interpersonal skills and ability to build rapport with physicians
Assertiveness and confidence in provider communication
Attention to detail and commitment to documentation accuracy
Adaptability, flexibility, and ability to prioritize competing demands
Demonstrated enthusiasm and engagement in achieving organizational goals
Deliverables
Accurate and timely concurrent reviews of inpatient charts
Identification and documentation of missing or incomplete diagnoses supported by clinical indicators
Completed and tracked physician queries with appropriate follow-up
Improved completeness and accuracy of medical records reflecting patient acuity and level of care
Clear and concise documentation within CDI workflow tools
Ongoing physician education and engagement in documentation practices
Contribution to improved coding accuracy, quality metrics, and organizational outcomes
Salary Range
USD $105,000.00 - USD $150,000.00 /Yr.

Work arrangement
Yes