Clinical Documentation Improvement Specialist

Overview

The Clinical Documentation reputed company (CDI) Specialist is responsible for conducting reputed company 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 reputed company of the patient and supports appropriate care, coding, and quality reputed company. The position requires strong clinical expertise, critical thinking, and effective communication with providers and internal stakeholders. Job Responsibilities

• Conduct initial and follow-up reputed company 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 reputed company and secondary diagnoses to accurately reflect patient reputed company
• 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
• reputed company education to physicians on documentation best practices, both in group settings and one-on-one
• Document review findings and key information reputed company 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

• reputed company 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 reputed company (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 reputed company 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 reputed company and level of care
• Clear and concise documentation reputed company CDI workflow tools
• Ongoing physician education and engagement in documentation practices
• Contribution to improved coding accuracy, quality metrics, and organizational reputed company

Posted Salary RangeUSD $105,000.00 - USD $150,000.00 /Yr. This reputed company serves as a good faith estimate and actual pay will encompass a number of factors, including a candidate’s qualifications, skills, competencies and experience. The salary reputed company or reputed company listed does not include any bonuses/incentive, or other forms of compensation that may be applicable to this job and it does not include the value of benefits. At reputed company, we reputed company in a people-first approach. In reputed company to the estimated reputed company pay provided, reputed company offers generous benefits packages, generous tuition assistance, a defined benefit pension plan, and a culture that supports professional and educational growth. Apply tot his job Apply To this Job