Clinical Documentation Improvement Specialist
Clinical Documentation Improvement Specialist
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1 Vacancy
Job Description
Job Summary:
The Clinical Documentation Improvement (CDI) Specialist primary responsibility is to ensure the inpatient medical record accurately supports severity of illness and risk of mortality as well as reflects the extent of care being provided and the resources being utilized for patients within the University Hospital system utilizing comprehensive and broad proficiency in complex clinical and medical concepts. This is achieved by both thoroughcomprehensiveconcurrent and retrospective medical record review for accuracy specificity and validation of clinical diagnosesthroughapplication of clinical documentation and ICD10 coding conventions as well as Centers for Medicare and Medicaid Services (CMS) rules and regulations. When inconsistencies incomplete documentation or opportunity for medical record clarification or optimization are identified the CDI Specialist will collaborate with the medical team to clarify necessary items through a dedicated and compliantwritten or verbalquery process. The CDI Specialist is also responsible for collaboration with the inpatient coding team to ensure the assigned final code set is reconciled prebill when necessary to resolve necessary discrepancies as well asprovider education related to documentation concepts both written and verbal achieved through both onsite and virtual education platforms including inperson rounds with the interdisciplinary care teamand attend various departmental and committee meetings.
Minimum Qualifications:
NYS Licensed/Registered (or eligible) RN Bachelors Degree in Nursing (or healthcare related field) and a minimum of three years post RN licensure acute care nursing experience or Associates Degree in Nursing and five years post RN licensure acute care nursing experience required. Must possess comprehensive and broad knowledge of complex clinical and medical concepts and demonstrate overall proficiency in clinical conceptual understanding for purposes of clinical validation. Strong communication skills both written and verbal as well as interpersonal skills required for interface and collaboration with leadership colleagues providers Physician Advisors regulatory agencies and other health care related entities required. Strong organizational skills with ability to manage assignments and responsibilities in hybrid work setting mostly independent communicating need for additional support or guidance when necessary. Proficiency in technology use including PC Windows Microsoft applications Zoom/WebEx platforms etc.
Preferred Qualifications:
Minimum 3 years recent inpatient nursing experiencein Med/Surg Stepdownor Critical Care setting preferably in an academic medical center setting highly desirable. Inpatient CDI or coding experience preferably in an academic medical center setting highly desirable. Knowledge of community state and federal laws and regulations including those of CMS preferred.
Work Days:
Monday Friday 8:00 am 4:30 pm
Message to Applicants:
This position is primarily remote with some onsite duties.
RecruitmentOffice: Human Resources
Executive Order:
Pursuant to Executive Order 161 no State entity as defined by the Executive Order is permitted to ask or mandate in any form that an applicant for employment provide his or her current compensation or any prior compensation history until such time as the applicant is extended a conditional offer of employment with compensation. If such information has been requested from you before such time please contact the Governors Office of Employee Relations ator via email at
Required Experience:
Unclear Seniority
Employment Type
Full-Time
