We are seeking a detail-oriented and collaborative Clinical Documentation Improvement (CDI) Specialist to join our team. In this role, you will bridge the gap between clinical care and data integrity, ensuring that medical records accurately reflect patient complexity, severity of illness, and the high-quality care provided by our facility.

Key Responsibilities

• Clinical Validation: Reviewing inpatient and/or outpatient records to ensure specificity, accuracy, and completeness.
• Provider Collaboration: Identifying documentation gaps and issuing professional, compliant queries to clinicians for necessary clarifications.
• Strategic Alignment: Partnering with Coding, Quality, and Revenue Cycle teams to optimize the Case Mix Index (CMI) and ensure appropriate reimbursement.
• Education & Advocacy: Serving as a subject matter expert by training physicians and clinical staff on documentation best practices and evolving regulatory standards.
• Performance Monitoring: Tracking essential KPIs, including query response rates and agreement metrics, to drive departmental success.
• Compliance & Auditing: Maintaining strict adherence to CMS and HIPAA guidelines while supporting internal and external audit processes.
• Continuous Learning: Staying ahead of the curve regarding ICD-10-CM/PCS updates and shifting payer regulations.

Qualifications

• Clinical Nursing Experience: Approximately 5 years of hands-on clinical experience. Must have a valid RN license (and be willing to obtain a New York license during the contract duration)
• CDI Experience: 2+ years of dedicated Clinical Documentation Improvement experience.
• Required Certification: Must hold an active CCDS, CCS, or RHIA credential.
• Coding Proficiency: Strong working knowledge of ICD-10-CM/PCS and payer regulations.
• Regulatory Compliance: Deep understanding of CMS, HIPAA, and documentation standards for SOI/ROM (Severity of Illness/Risk of Mortality).
• Communication: Proven ability to collaborate with and educate physicians and clinical staff.

Logistics

• Schedule: Monday – Friday (Standard Business Hours)
• Shift: Choice of 8am–4pm or 9am–5pm
• Time Zone: Must work EST hours
• Duration: Direct Hire / Permanent